Provider Demographics
NPI:1548468762
Name:EVERGREEN BEHAVIORAL MANAGEMENT OF GEORGIA, INC.
Entity type:Organization
Organization Name:EVERGREEN BEHAVIORAL MANAGEMENT OF GEORGIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-641-0600
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-0425
Mailing Address - Country:US
Mailing Address - Phone:910-641-0600
Mailing Address - Fax:910-641-4178
Practice Address - Street 1:8657 HOSPITAL DR
Practice Address - Street 2:SUITE 101 A
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2298
Practice Address - Country:US
Practice Address - Phone:770-949-3118
Practice Address - Fax:770-949-3228
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN BEHAVIORAL MANAGEMENT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-10
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)