Provider Demographics
NPI:1568824357
Name:EVERGREEN REAL ESTATE DEV. CORP
Entity Type:Organization
Organization Name:EVERGREEN REAL ESTATE DEV. CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLENAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-447-2345
Mailing Address - Street 1:16670 FRANKLIN TRL SE
Mailing Address - Street 2:240
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2924
Mailing Address - Country:US
Mailing Address - Phone:952-447-2345
Mailing Address - Fax:952-447-2344
Practice Address - Street 1:16670 FRANKLIN TRL SE
Practice Address - Street 2:240
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-2924
Practice Address - Country:US
Practice Address - Phone:952-447-2345
Practice Address - Fax:952-447-2344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA332U00000X
333300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
No333300000XSuppliersEmergency Response System Companies