Evergreen Manor III, Inc

Primary specialty

Mental Illness Community Based Residential Treatment FacilityTaxonomy code 320800000X

License

0011807 Issued in WI

Legal business name

EVERGREEN MANOR III, INC

Practice address

8429 Idyllview Ave
Sparta, WI 54656-3617

Phone

(608) 487-9067

Fax

(608) 487-9067

NPI assigned

Nov 18, 2009

Last updated

Nov 18, 2009By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Larenda L Rosin

Title

President

Phone

(608) 487-9067

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1258502400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1258502400000",
    "number": "1033447776",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8429 IDYLLVIEW AVE",
            "city": "SPARTA",
            "state": "WI",
            "postal_code": "546563617",
            "telephone_number": "608-487-9067",
            "fax_number": "608-487-9067"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8429 IDYLLVIEW AVE",
            "city": "SPARTA",
            "state": "WI",
            "postal_code": "546563617",
            "telephone_number": "608-487-9067",
            "fax_number": "608-487-9067"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN MANOR III, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-18",
        "last_updated": "2009-11-18",
        "status": "A",
        "authorized_official_last_name": "ROSIN",
        "authorized_official_first_name": "LARENDA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "608-487-9067",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": "WI",
            "license": "0011807",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Nicholas W Ekern, LMT
• Matthew J Englerth
• Theresa Ertl, RN
• Kurt Charles Euller, PH.D.
• Evergreen Manor II
• Evergreen Manor,Inc.
• Family & Childrens Center
• Austin W Feltner
• Ariel Dawn Ferdock, PHARMD
• Dawn Fitzmaurice, RN

• Mental Illness Community Based Residential Treatment Facility in Sparta, WI
• Providers in Sparta, WI by specialty
• Mental Illness Community Based Residential Treatment Facility in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.