MEDICARE: EVERSHINE CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	1T3533	NM

General Provider Information

NPI Number	:	1043688088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERSHINE CARE, LLC

Provider Business Mailing Address
First Line	:	4844 CALLE BELLA AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-7066
Country	:	US
Telephone Number	:	575-382-5973
Fax Number	:

Provider Business Practice Location Address
First Line	:	4844 CALLE BELLA AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-7066
Country	:	US
Telephone Number	:	575-382-5973
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. IVAN NNAMDI NWAOGU
Credential	:	PHARMD
Telephone Number	:	575-382-5973

Provider Enumeration Date	:	09/08/2015
Last Update Date	:	09/08/2015

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