Provider Demographics
NPI:1780206250
Name:EVERGREEN ASSISTED LIVING COMMUNITY LLC
Entity Type:Organization
Organization Name:EVERGREEN ASSISTED LIVING COMMUNITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATIENCE
Authorized Official - Middle Name:OGWA
Authorized Official - Last Name:ODUPELU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-613-0757
Mailing Address - Street 1:4222 MOOMAW AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-4314
Mailing Address - Country:US
Mailing Address - Phone:540-613-0757
Mailing Address - Fax:540-491-9319
Practice Address - Street 1:4222 MOOMAW AVE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-4314
Practice Address - Country:US
Practice Address - Phone:540-613-0757
Practice Address - Fax:540-491-9319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities