Healthcare Provider Details

I. General information

NPI: 1063982627
Provider Name (Legal Business Name): EVERGREEN ADC HAWAII
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 FORT STREET MALL FL 2
HONOLULU HI
96813-2715
US

IV. Provider business mailing address

1124 FORT STREET MALL FL 2
HONOLULU HI
96813-2715
US

V. Phone/Fax

Practice location:
  • Phone: 808-372-8257
  • Fax: 808-946-7571
Mailing address:
  • Phone: 808-372-8257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIEL PARK
Title or Position: OWNER
Credential:
Phone: 808-372-8257