Healthcare Provider Details

I. General information

NPI: 1861688087
Provider Name (Legal Business Name): EVERGREENS ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8795 MISSION RD
JESSUP MD
20794-3943
US

IV. Provider business mailing address

8795 MISSION RD
JESSUP MD
20794-3943
US

V. Phone/Fax

Practice location:
  • Phone: 301-604-1761
  • Fax: 301-490-6256
Mailing address:
  • Phone: 301-604-1761
  • Fax: 301-490-6256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number13AL160
License Number StateMD

VIII. Authorized Official

Name: MARIAN GRENWAY
Title or Position: MANAGER
Credential:
Phone: 301-604-1761