Healthcare Provider Details

I. General information

NPI: 1649724089
Provider Name (Legal Business Name): EVERGREEN ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2016
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
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:
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 Number1-0816
License Number StateHI

VIII. Authorized Official

Name: DANIEL J PARK
Title or Position: OWNER
Credential:
Phone: 808-946-7505