=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992502595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN SENIOR CARE SERVICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2025
-----------------------------------------------------
Last Update Date | 03/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9701 S 200TH ST
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98031-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-856-2790
-----------------------------------------------------
Fax | 253-981-3156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9701 S 200TH ST
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98031-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-856-2790
-----------------------------------------------------
Fax | 253-981-3156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TAWEKE S GEBRESELASSIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-856-2790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------