Provider Demographics
NPI:1457689192
Name:EVERGREEN MANOR II
Entity Type:Organization
Organization Name:EVERGREEN MANOR II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LARENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-487-9067
Mailing Address - Street 1:8429 IDYLLVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-3617
Mailing Address - Country:US
Mailing Address - Phone:608-487-9067
Mailing Address - Fax:608-487-9067
Practice Address - Street 1:8429 IDYLLVIEW AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-3617
Practice Address - Country:US
Practice Address - Phone:608-487-9067
Practice Address - Fax:608-487-9067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0011268320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness