Provider Demographics
NPI:1396984373
Name:EVERGREEN BEHAVIORAL
Entity type:Organization
Organization Name:EVERGREEN BEHAVIORAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-641-0600
Mailing Address - Street 1:P.O. BOX 425
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-2220
Mailing Address - Country:US
Mailing Address - Phone:910-641-0600
Mailing Address - Fax:910-641-0606
Practice Address - Street 1:1409 PINCKNEY STREET
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?:Yes
Parent Organization LBN:EVERGREEN BEHAVIORAL MANAGEMENT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-13
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8702201Medicaid
NC3408980Medicaid