Provider Demographics
NPI:1578658639
Name:EVERGREEN ELDER CARE, INC.
Entity Type:Organization
Organization Name:EVERGREEN ELDER CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:210-826-2116
Mailing Address - Street 1:7340 BLANCO RD
Mailing Address - Street 2:SUITE 1122
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4966
Mailing Address - Country:US
Mailing Address - Phone:210-826-2116
Mailing Address - Fax:210-525-8979
Practice Address - Street 1:7340 BLANCO RD
Practice Address - Street 2:SUITE 1122
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4966
Practice Address - Country:US
Practice Address - Phone:210-826-2116
Practice Address - Fax:210-525-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1728479-01Medicaid
TX31420501578216-8001OtherTRICARE GROUP NUMBER
TX00299VMedicare ID - Type UnspecifiedPROVIDER NUMBER