Provider Demographics
NPI:1528206174
Name:EVERGREEN BEHAVIORAL MANAGEMENT, INC.
Entity Type:Organization
Organization Name:EVERGREEN BEHAVIORAL MANAGEMENT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-640-5512
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-0425
Mailing Address - Country:US
Mailing Address - Phone:910-640-5512
Mailing Address - Fax:910-641-0606
Practice Address - Street 1:416 FAIRLEY ST
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-3612
Practice Address - Country:US
Practice Address - Phone:910-276-8545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302543Medicaid