=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821350638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN PRIVATE CARE OF HOUSTON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2012
-----------------------------------------------------
Last Update Date | 03/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16818 N. ELDRIDGE PARKWAY
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-320-1856
-----------------------------------------------------
Fax | 281-320-1886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2650 COLLEGE STATION MOUNTAIN RD
-----------------------------------------------------
City | PIKEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37367-4435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-545-2945
-----------------------------------------------------
Fax | 855-841-4224
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JERRY WHEELER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-888-9099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------