Provider Demographics
NPI:1831905348
Name:4 EVERGREEN RECOVERY HOMES AND SERVICES
Entity type:Organization
Organization Name:4 EVERGREEN RECOVERY HOMES AND SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COBLAH
Authorized Official - Middle Name:Q
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-908-5858
Mailing Address - Street 1:3210 VICKERS RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-1940
Mailing Address - Country:US
Mailing Address - Phone:443-924-3754
Mailing Address - Fax:
Practice Address - Street 1:3210 VICKERS RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-1940
Practice Address - Country:US
Practice Address - Phone:443-924-3754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness