Healthcare Provider Details

I. General information

NPI: 1104821537
Provider Name (Legal Business Name): EVERGREEN HOME HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 10/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17215 STUDEBAKER RD STE 270
CERRITOS CA
90703-2522
US

IV. Provider business mailing address

17215 STUDEBAKER RD STE 270
CERRITOS CA
90703-2522
US

V. Phone/Fax

Practice location:
  • Phone: 562-860-9444
  • Fax: 562-860-8334
Mailing address:
  • Phone: 562-860-9444
  • Fax: 562-860-8334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. LYDIA Y AHN
Title or Position: ADMINISTRATOR/CEO
Credential: RN, PHN
Phone: 562-860-9444