Provider Demographics
NPI:1609014190
Name:EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Entity Type:Organization
Organization Name:EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Other - Org Name:SELA COMMUNITY SERVICES SIL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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 1:906 C M FAGAN DR
Practice Address - Street 2:SUITE 6-A
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-6056
Practice Address - Country:US
Practice Address - Phone:985-543-6591
Practice Address - Fax:985-543-6638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9957320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA9957Medicaid