Provider Demographics
NPI:1487719662
Name:EVERGREEN RESIDENTIAL CARE
Entity type:Organization
Organization Name:EVERGREEN RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:DARCY
Authorized Official - Last Name:FORSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-272-2601
Mailing Address - Street 1:2374 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3006
Mailing Address - Country:US
Mailing Address - Phone:801-272-2601
Mailing Address - Fax:801-278-3697
Practice Address - Street 1:2374 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-3006
Practice Address - Country:US
Practice Address - Phone:801-272-2601
Practice Address - Fax:801-278-3697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2919310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility