Provider Demographics
NPI:1588816789
Name:EVERGREEN BEHAVIORAL MANAGEMENT, INC.
Entity Type:Organization
Organization Name:EVERGREEN BEHAVIORAL MANAGEMENT, INC.
Other - Org Name:BRENTON HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-641-0600
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-0425
Mailing Address - Country:US
Mailing Address - Phone:910-641-0600
Mailing Address - Fax:910-641-0606
Practice Address - Street 1:5794 OLD HIGHWAY 74
Practice Address - Street 2:
Practice Address - City:CHADBOURN
Practice Address - State:NC
Practice Address - Zip Code:28431-6779
Practice Address - Country:US
Practice Address - Phone:910-654-3591
Practice Address - Fax:910-654-3591
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN BEHAVIORAL MANAGEMENT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL024074322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603239Medicaid