=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447025614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN VALLEY HOME HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2023
-----------------------------------------------------
Last Update Date | 12/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 S 1ST ST # 207
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95113-2835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-416-3030
-----------------------------------------------------
Fax | 408-834-7618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 S 1ST ST # 200
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95113-2835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-416-3030
-----------------------------------------------------
Fax | 408-834-7618
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PRESIDENT
-----------------------------------------------------
Name | CORY TRAN
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 408-416-3030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------