Healthcare Provider Details

I. General information

NPI: 1750496667
Provider Name (Legal Business Name): EVERGREEN HOME CARE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date: 11/30/2018
Reactivation Date: 12/08/2018

III. Provider practice location address

6041 DEMPSTER ST
MORTON GROVE IL
60053
US

IV. Provider business mailing address

6041 DEMPSTER ST
MORTON GROVE IL
60053-2943
US

V. Phone/Fax

Practice location:
  • Phone: 847-470-9280
  • Fax: 847-470-9282
Mailing address:
  • Phone: 847-470-9280
  • Fax: 847-470-9928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1010796
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateIL

VIII. Authorized Official

Name: GLORIA S KIM
Title or Position: PRESIDENT
Credential: RN
Phone: 847-470-9280