MEDICARE: EVERGREEN ASSISTED LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1033401500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	6521 CLEARHAVEN CIR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-4017
Country	:	US
Telephone Number	:	972-735-9604
Fax Number	:	972-735-9602

Provider Business Practice Location Address
First Line	:	6521 CLEARHAVEN CIR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-4017
Country	:	US
Telephone Number	:	972-735-9604
Fax Number	:	972-735-9602

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	VINIL PATEL
Credential	:
Telephone Number	:	972-735-9604

Provider Enumeration Date	:	05/03/2011
Last Update Date	:	05/03/2011

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