Healthcare Provider Details

I. General information

NPI: 1457565780
Provider Name (Legal Business Name): EVERGREEN HEALTHCARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 VIENNA AVE
NILES OH
44446
US

IV. Provider business mailing address

EVERGREEN HEALTHCARE SERVICES, INC. PO BOX 221
NILES OH
44446
US

V. Phone/Fax

Practice location:
  • Phone: 330-652-3355
  • Fax: 330-652-1477
Mailing address:
  • Phone: 330-652-3355
  • Fax: 330-652-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number2437643
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number2437643
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number0019704300003
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number2437643
License Number StateOH

VIII. Authorized Official

Name: MS. DEBORAH N BAILEY
Title or Position: PRESIDENT
Credential: MED
Phone: 330-652-3355