NPIMap

Organization Active NPI

Evergreen Presbyterian Ministries of Texas, Inc.

Doing business as Evergreen Fortune Community Home

  • Intellectual Disabilities Intermediate Care Facility
  • Texarkana, TX
National Provider Identifier
1245376763
Registry record updated Jun 16, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
116558 Issued in TX
Legal business name
EVERGREEN PRESBYTERIAN MINISTRIES OF TEXAS, INC.
Doing business as
Evergreen Fortune Community Home
Practice address
3002 Fortune Ave
Texarkana, TX 75503-1561
Phone
(903) 838-5625
NPI assigned
Jan 30, 2007
Last updated
Jun 16, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 16, 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 116558 TX Primary

Addresses

Primary practice location

3002 Fortune Ave
Texarkana, TX 75503-1561

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
000724801MedicaidTX

Other names 1

  • Evergreen Fortune 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 1245376763. Details of each certification follow.

  • CCN 45G471 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 45G471

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
EVERGREEN FORTUNE COMMUNITY HOME
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Mar 20, 1991
Last certification
Jan 23, 2025
Beds
6
Ownership / control type
Private (non-profit)
Facility address
3002 Fortune Ave
Texarkana, TX 75503

National Provider Directory

National Provider Directory
Tax ID family
Evergreen Presbyterian Ministries of Texas Inc33 organizations share this tax ID, including this one

Other organizations with this tax ID 32

Organizations that report the same tax identification number in the National Provider Directory.

View all 32

NPI Registry JSON

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

{
    "created_epoch": "1170115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1213574400000",
    "number": "1245376763",
    "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": "3002 FORTUNE AVE",
            "city": "TEXARKANA",
            "state": "TX",
            "postal_code": "755031561",
            "telephone_number": "903-838-5625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN PRESBYTERIAN MINISTRIES OF TEXAS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-30",
        "last_updated": "2008-06-16",
        "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": "TX",
            "license": "116558",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000724801",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Fortune Community Home",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Texarkana, TX

Sources for this page

Verify at the official NPI Registry.