MEDICARE: EVERGREEN HOME CARE, 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1295328110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN HOME CARE, LLC

Provider Business Mailing Address
First Line	:	2529 W DARREL RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6457
Country	:	US
Telephone Number	:	619-882-0072
Fax Number	:

Provider Business Practice Location Address
First Line	:	2529 W DARREL RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6457
Country	:	US
Telephone Number	:	619-882-0072
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MOHAMED DAHIR
Credential	:
Telephone Number	:	619-882-0072

Provider Enumeration Date	:	02/11/2021
Last Update Date	:	02/11/2021

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