Provider Demographics
NPI:1346068731
Name:EVERGREEN COMMUNITY & SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:EVERGREEN COMMUNITY & SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COSTAN
Authorized Official - Middle Name:JAYA
Authorized Official - Last Name:BALGOBIN
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:954-464-0256
Mailing Address - Street 1:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-0333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4123 STONECREST CT # 102
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7762
Practice Address - Country:US
Practice Address - Phone:954-464-0256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty