Provider Demographics
NPI:1205589173
Name:EVERGREEN COMMUNITY HOMES INC
Entity type:Organization
Organization Name:EVERGREEN COMMUNITY HOMES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NGOZI
Authorized Official - Middle Name:GLORIA
Authorized Official - Last Name:WILKENS
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:443-642-9933
Mailing Address - Street 1:13 BROADBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-1558
Mailing Address - Country:US
Mailing Address - Phone:443-642-9933
Mailing Address - Fax:
Practice Address - Street 1:13 BROADBRIDGE RD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-1558
Practice Address - Country:US
Practice Address - Phone:443-642-9933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities