Healthcare Provider Details

I. General information

NPI: 1467314070
Provider Name (Legal Business Name): EVERGREEN HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 GOLANSKY BLVD
WOODBRIDGE VA
22192-4223
US

IV. Provider business mailing address

3115 GOLANSKY BLVD
WOODBRIDGE VA
22192-4223
US

V. Phone/Fax

Practice location:
  • Phone: 571-295-3879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: ELSIE ADONTENG-BOATENG
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 571-295-3879