Provider Demographics
NPI:1538287263
Name:EVERGREEN PLACE
Entity Type:Organization
Organization Name:EVERGREEN PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR-CEO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-349-3312
Mailing Address - Street 1:201 8TH ST N
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:ND
Mailing Address - Zip Code:58436-7341
Mailing Address - Country:US
Mailing Address - Phone:701-349-4550
Mailing Address - Fax:701-349-4656
Practice Address - Street 1:241 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ELLENDALE
Practice Address - State:ND
Practice Address - Zip Code:58436
Practice Address - Country:US
Practice Address - Phone:701-349-4550
Practice Address - Fax:701-349-4656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND30729310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND30729Medicaid