Provider Demographics
NPI:1790860971
Name:EVERGREEN BEHAVIORAL MANAGEMENT INC
Entity Type:Organization
Organization Name:EVERGREEN BEHAVIORAL MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO OWNER OF COMPANY
Authorized Official - Phone:910-641-0600
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-0425
Mailing Address - Country:US
Mailing Address - Phone:910-641-0600
Mailing Address - Fax:910-641-0606
Practice Address - Street 1:1409 PINCKNEY ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-2220
Practice Address - Country:US
Practice Address - Phone:910-641-0600
Practice Address - Fax:910-641-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015VMMedicaid
NC6005966Medicaid
NC6005966Medicaid