Provider Demographics
NPI:1598936528
Name:EVERGREEN ELM, INC.
Entity Type:Organization
Organization Name:EVERGREEN ELM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:I
Authorized Official - Last Name:PUGRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-362-6853
Mailing Address - Street 1:71 MAIN STREET, SUITE 303
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-2029
Mailing Address - Country:US
Mailing Address - Phone:814-362-6853
Mailing Address - Fax:814-362-1048
Practice Address - Street 1:71 MAIN STREET, SUITE 303
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-2029
Practice Address - Country:US
Practice Address - Phone:814-362-6853
Practice Address - Fax:814-362-1048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA426070320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities