Healthcare Provider Details

I. General information

NPI: 1710391990
Provider Name (Legal Business Name): EVERGREEN HOME HEALTH CARE AGENCY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 LAKE VIEW BLVD
EDISON NJ
08817-5419
US

IV. Provider business mailing address

13 LAKE VIEW BLVD
EDISON NJ
08817-5419
US

V. Phone/Fax

Practice location:
  • Phone: 848-459-8301
  • Fax: 888-664-5617
Mailing address:
  • Phone: 848-459-8301
  • Fax: 888-664-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHP0187200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. ROSALINE SHAU
Title or Position: VICE PRESIDENT
Credential:
Phone: 848-459-8301