=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447061924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN HOME HEALTHCARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2025
-----------------------------------------------------
Last Update Date | 09/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2621 S HEIGHTS DR NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-469-7560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16386 ELLERDALE LN
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55346-1411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-469-7560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTED LIVING DIRECTOR
-----------------------------------------------------
Name | MRS. MARIAMA MARIE SAIDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-469-7560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------