Provider Demographics
NPI:1639917313
Name:EVERGREEN SUPPORTIVE CARE, LLC
Entity type:Organization
Organization Name:EVERGREEN SUPPORTIVE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-532-5583
Mailing Address - Street 1:7244 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-5018
Mailing Address - Country:US
Mailing Address - Phone:314-532-5583
Mailing Address - Fax:314-200-2682
Practice Address - Street 1:7244 HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-5018
Practice Address - Country:US
Practice Address - Phone:314-532-5583
Practice Address - Fax:314-200-2682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)