NPIMap

Organization Active NPI

Evergreen Presbyterian Ministries, Inc.

Doing business as Second Avenue Community Home

  • Intellectual Disabilities Intermediate Care Facility
  • Lake Charles, LA
National Provider Identifier
1215081302
Registry record updated Jun 13, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
608 Issued in LA
Legal business name
EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Doing business as
Second Avenue Community Home
Practice address
2410 2ND Ave
Lake Charles, LA 70601-7760
Phone
(337) 497-1141
NPI assigned
Jan 23, 2007
Last updated
Jun 13, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 13, 2008

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

Authorized official

Name
John R Taylor
Title
President
Phone
(318) 949-5500

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 608 LA Primary

Addresses

Primary practice location

2410 2ND Ave
Lake Charles, LA 70601-7760

Mailing address

2101 Highway 80
Haughton, LA 71037-9488
Phone (318) 949-5500

Other identifiers 1

IdentifierTypeStateIssuer
1718602MedicaidLA

Other names 1

  • Second Avenue Community Home Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1215081302. Details of each certification follow.

  • CCN 19G348 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 19G348

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
Second Avenue Community Home
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Jan 18, 1990
Last certification
Mar 5, 2025
Beds
6
Ownership / control type
Private (non-profit)
Facility address
2410 2nd Avenue
Lake Charles, LA 70601

National Provider Directory

National Provider Directory
Tax ID family
Evergreen Ok Transportation120 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

NPI Registry JSON

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

{
    "created_epoch": "1169510400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1213315200000",
    "number": "1215081302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2101 HIGHWAY 80",
            "city": "HAUGHTON",
            "state": "LA",
            "postal_code": "710379488",
            "telephone_number": "318-949-5500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2410 2ND AVE",
            "city": "LAKE CHARLES",
            "state": "LA",
            "postal_code": "706017760",
            "telephone_number": "337-497-1141"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN PRESBYTERIAN MINISTRIES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-23",
        "last_updated": "2008-06-13",
        "status": "A",
        "authorized_official_last_name": "TAYLOR",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "318-949-5500"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "LA",
            "license": "608",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1718602",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Second Avenue Community Home",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Charles, LA

Sources for this page

Verify at the official NPI Registry.