Provider Demographics
NPI:1598083867
Name:EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Entity Type:Organization
Organization Name:EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Other - Org Name:IVY SPRINGS COMMUNITY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-949-5500
Mailing Address - Street 1:2101 HIGHWAY 80
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-9488
Mailing Address - Country:US
Mailing Address - Phone:318-949-5500
Mailing Address - Fax:318-949-5555
Practice Address - Street 1:27683 IVY SPRINGS DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443-4927
Practice Address - Country:US
Practice Address - Phone:318-949-5500
Practice Address - Fax:318-949-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAPPLIED FORMedicaid