Organization
EVERGREEN DICKINSON, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. VICKIE COFER (ASST. DIRECTOR)
(701) 483-6606
Entity
Organization
Contact information
Practice address
2143 6TH AVE W, DICKINSON, ND 58601-2700
(701) 483-6606
Mailing address
2143 6TH AVE W, DICKINSON, ND 58601-2700
(701) 483-6606
Taxonomy
Speciality
Code
Description
License number
State
311Z00000X
Custodial Care Facility
Primary
8054A
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
030765
—
ND
Enumeration date
06/26/2007
Last updated
11/18/2008
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