Provider Demographics
NPI:1215470992
Name:EVERGREEN ELM, INC.
Entity type:Organization
Organization Name:EVERGREEN ELM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUMBULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-362-6853
Mailing Address - Street 1:50 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-6516
Mailing Address - Country:US
Mailing Address - Phone:814-362-6853
Mailing Address - Fax:814-362-1048
Practice Address - Street 1:50 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-6516
Practice Address - Country:US
Practice Address - Phone:814-362-6853
Practice Address - Fax:814-362-1048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care