Healthcare Provider Details

I. General information

NPI: 1962952119
Provider Name (Legal Business Name): EVERGREEN EAST ORANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 EVERGREEN PL
EAST ORANGE NJ
07018-2101
US

IV. Provider business mailing address

395 NEW DOVER RD
COLONIA NJ
07067-2703
US

V. Phone/Fax

Practice location:
  • Phone: 732-986-6978
  • Fax:
Mailing address:
  • Phone: 732-986-6978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DIVYESH A MEHTA
Title or Position: MANAGER
Credential:
Phone: 732-208-4833