NPIMap

Organization Active NPI

Evergreen Living Home Inc.

Doing business as Evergreen Living Home # 1

  • Adult Care Home Facility
  • Leicester, NC
National Provider Identifier
1346361102
Registry record updated Sep 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adult Care Home FacilityTaxonomy code 311ZA0620X
License
FCL-011-193 Issued in NC
Legal business name
EVERGREEN LIVING HOME INC.
Doing business as
Evergreen Living Home # 1
Practice address
101 Country Time LN
Leicester, NC 28748
Phone
(828) 779-5588
NPI assigned
Apr 2, 2007
Last updated
Sep 8, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 8, 2023

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

Authorized official

Name
Young Song Lee
Title
Owner
Phone
(828) 779-5588

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Adult Care Home Facility 311ZA0620X FCL-011-193 NC Primary

Addresses

Primary practice location

101 Country Time LN
Leicester, NC 28748

Mailing address

PO Box 2077
Leicester, NC 28748-2077
Phone (828) 779-5588

Other identifiers 1

IdentifierTypeStateIssuer
7805223MedicaidNC

Other names 1

  • EVERGREEN LIVING HOME # 1 Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Evergreen Living 419 organizations share this tax ID, including this one

Other organizations with this tax ID 18

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

View all 18

NPI Registry JSON

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

{
    "created_epoch": "1175472000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694131200000",
    "number": "1346361102",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2077",
            "city": "LEICESTER",
            "state": "NC",
            "postal_code": "287482077",
            "telephone_number": "828-779-5588"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 COUNTRY TIME LN",
            "city": "LEICESTER",
            "state": "NC",
            "postal_code": "28748",
            "telephone_number": "828-779-5588"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN LIVING HOME INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-02",
        "last_updated": "2023-09-08",
        "certification_date": "2023-09-08",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "YOUNG",
        "authorized_official_middle_name": "SONG",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "828-779-5588"
    },
    "taxonomies": [
        {
            "code": "311ZA0620X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility, Adult Care Home",
            "state": "NC",
            "license": "FCL-011-193",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7805223",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "EVERGREEN LIVING HOME # 1",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Leicester, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2023; 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.