Healthcare Provider Details

I. General information

NPI: 1861607517
Provider Name (Legal Business Name): EVERGREEN COMMONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 STATE ST
HOLLAND MI
49423-4832
US

IV. Provider business mailing address

480 STATE ST
HOLLAND MI
49423-4832
US

V. Phone/Fax

Practice location:
  • Phone: 616-396-7100
  • Fax: 616-396-9736
Mailing address:
  • Phone: 616-396-7100
  • Fax: 616-396-9736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUZZANNE SHOLES
Title or Position: DIRECTOR OF THE DAY CENTER
Credential:
Phone: 269-352-9029