Healthcare Provider Details

I. General information

NPI: 1255250098
Provider Name (Legal Business Name): EVERGREEN HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2761 MILTON RD
CHARLOTTESVILLE VA
22902-7602
US

IV. Provider business mailing address

2761 MILTON RD
CHARLOTTESVILLE VA
22902-7602
US

V. Phone/Fax

Practice location:
  • Phone: 347-392-9898
  • Fax: 347-392-9898
Mailing address:
  • Phone: 347-392-9898
  • Fax: 347-392-9898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MELLISSA JACOB
Title or Position: MANAGER
Credential:
Phone: 240-207-8382