Provider Demographics
NPI:1619559812
Name:EVERGREEN MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:EVERGREEN MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-578-2480
Mailing Address - Street 1:PO BOX 706
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:AL
Mailing Address - Zip Code:36401-0706
Mailing Address - Country:US
Mailing Address - Phone:251-578-2480
Mailing Address - Fax:
Practice Address - Street 1:225 PATTERSON AVE # A
Practice Address - Street 2:
Practice Address - City:GEORGIANA
Practice Address - State:AL
Practice Address - Zip Code:36033-6628
Practice Address - Country:US
Practice Address - Phone:251-578-2480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health