Healthcare Provider Details

I. General information

NPI: 1427178540
Provider Name (Legal Business Name): EVERGREEN LIVING HOME INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 FAMILY RIDGE ROAD
LEICESTER NC
28748
US

IV. Provider business mailing address

PO BOX 2077
LEICESTER NC
28748-2077
US

V. Phone/Fax

Practice location:
  • Phone: 828-779-5588
  • Fax:
Mailing address:
  • Phone: 828-779-5588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-011-196
License Number StateNC

VIII. Authorized Official

Name: YOUNG SONG LEE
Title or Position: OWNER
Credential:
Phone: 828-779-5588