Provider Demographics
NPI:1578892147
Name:EVERGREEN HEALING CENTER, LLC
Entity Type:Organization
Organization Name:EVERGREEN HEALING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:TREMAINE
Authorized Official - Last Name:BRIDGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:207-512-0584
Mailing Address - Street 1:218 COTTRELL RD
Mailing Address - Street 2:
Mailing Address - City:DIXMONT
Mailing Address - State:ME
Mailing Address - Zip Code:04932-3246
Mailing Address - Country:US
Mailing Address - Phone:207-512-0584
Mailing Address - Fax:207-234-4334
Practice Address - Street 1:224 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3434
Practice Address - Country:US
Practice Address - Phone:207-512-0584
Practice Address - Fax:207-990-6604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175F00000X, 363LF0000X
MEAP081246261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME246520000Medicaid
ME246520000Medicaid
MENP0646Medicare PIN