Organization
EVERGREEN MANOR III, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LARENDA L ROSIN (PRESIDENT)
(608) 487-9067
Entity
Organization
Contact information
Practice address
8429 IDYLLVIEW AVE, SPARTA, WI 54656-3617
(608) 487-9067
(608) 487-9067
Mailing address
8429 IDYLLVIEW AVE, SPARTA, WI 54656-3617
(608) 487-9067
(608) 487-9067
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
0011807
WI
Other
Enumeration date
11/18/2009
Last updated
11/18/2009
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