=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760138317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN HEALTH CARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2022
-----------------------------------------------------
Last Update Date | 02/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7821 JEREMY TER
-----------------------------------------------------
City | DERWOOD
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20855-1113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-418-3818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7821 JEREMY TER
-----------------------------------------------------
City | DERWOOD
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20855-1113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-418-3818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ISATU R SISAY
-----------------------------------------------------
Credential | NURSE
-----------------------------------------------------
Telephone | 240-418-3818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------