Healthcare Provider Details

I. General information

NPI: 1235647348
Provider Name (Legal Business Name): EVERGREEN HEALTH CARE MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4115 ANNANDALE ROAD, SUITE 208
ANNANDALE VA
22003-2200
US

IV. Provider business mailing address

8868 WINDING HOLLOW WAY
SPRINGFIELD VA
22152-1449
US

V. Phone/Fax

Practice location:
  • Phone: 703-534-5049
  • Fax: 888-588-3957
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHCO-1805
License Number StateVA

VIII. Authorized Official

Name: JIN CHOI
Title or Position: OWNER
Credential: RN
Phone: 571-505-1119