| Organization Name: | EVERGREEN MANOR III, INC |
| NPI Number: | 1033447776 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LARENDA L ROSIN (PRESIDENT) |
| Mailing Address: | 8429 Idyllview Ave Sparta |
| State: | WI US |
| Postal Code: | 546563617 |
| Phone Number: | 6084879067 |
| Fax Number: | 6084879067 |
| NPI Enumeration Date: | 11/18/2009 |
| NPI Last Update Date: | 11/18/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320800000X |
| License Number: | 0011807 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Community Based Residential Treatment Facility, Mental Illness |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A home-like residential facility providing psychiatric treatment and psycho/social rehabilitative services to individuals diagnosed with mental illness. |