Provider Demographics
NPI:1558015248
Name:EVERGREEN CONGREGATE, LLC
Entity Type:Organization
Organization Name:EVERGREEN CONGREGATE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:CORTLAND
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-397-0658
Mailing Address - Street 1:27702 CROWN VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0608
Mailing Address - Country:US
Mailing Address - Phone:949-397-0658
Mailing Address - Fax:
Practice Address - Street 1:823 TOWNE ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3509
Practice Address - Country:US
Practice Address - Phone:949-397-0658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities