Provider Demographics
NPI:1871638999
Name:EVERGREEN GROUP HOME, LLC
Entity Type:Organization
Organization Name:EVERGREEN GROUP HOME, LLC
Other - Org Name:EVERGREEN GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-722-4416
Mailing Address - Street 1:27 HOPPER TRL
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:MO
Mailing Address - Zip Code:65767-9234
Mailing Address - Country:US
Mailing Address - Phone:417-722-4416
Mailing Address - Fax:417-722-4417
Practice Address - Street 1:27 HOPPER TRL
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:MO
Practice Address - Zip Code:65767-9234
Practice Address - Country:US
Practice Address - Phone:417-722-4416
Practice Address - Fax:417-722-4417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO91438201670000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty