Healthcare Provider Details

I. General information

NPI: 1306750542
Provider Name (Legal Business Name): EVERGREEN ADULT FOSTER CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 JONATHAN CIR
WORCESTER MA
01604-2242
US

IV. Provider business mailing address

12 JONATHAN CIR
WORCESTER MA
01604-2242
US

V. Phone/Fax

Practice location:
  • Phone: 931-378-1371
  • Fax:
Mailing address:
  • Phone: 931-378-1371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: CAROLINE OPONDO
Title or Position: RN - MANAGER
Credential: RN
Phone: 931-378-1371