Provider Demographics
NPI:1811795370
Name:EVERGREEN TEAM HOLDINGS LLC
Entity type:Organization
Organization Name:EVERGREEN TEAM HOLDINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-206-5204
Mailing Address - Street 1:16745 BIG BEAR RD
Mailing Address - Street 2:
Mailing Address - City:LOWER LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95457-9712
Mailing Address - Country:US
Mailing Address - Phone:707-206-5204
Mailing Address - Fax:
Practice Address - Street 1:3642 BLUE GUM ST
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-7939
Practice Address - Country:US
Practice Address - Phone:707-266-9150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No177F00000XOther Service ProvidersLodging
No385H00000XRespite Care FacilityRespite Care