Provider Demographics
NPI:1588652051
Name:EVERGREEN HEALTHCARE CENTER
Entity type:Organization
Organization Name:EVERGREEN HEALTHCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADON/ MEDICARE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:940-704-6682
Mailing Address - Street 1:406 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BURKBURNETT
Mailing Address - State:TX
Mailing Address - Zip Code:76354-2017
Mailing Address - Country:US
Mailing Address - Phone:940-569-2236
Mailing Address - Fax:940-569-1299
Practice Address - Street 1:406 E 7TH ST
Practice Address - Street 2:
Practice Address - City:BURKBURNETT
Practice Address - State:TX
Practice Address - Zip Code:76354-2017
Practice Address - Country:US
Practice Address - Phone:940-569-2236
Practice Address - Fax:940-569-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004413Medicaid
TX675035Medicare ID - Type Unspecified