MEDICARE: EVERGREEN THERAPY SERVICES, INC

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	:	1396058590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN THERAPY SERVICES, INC

Provider Business Mailing Address
First Line	:	220 71ST ST
Second Line	:	STE 217
City	:	MIAMI BEACH
State	:	FL
Zip	:	33141-3295
Country	:	US
Telephone Number	:	786-333-0844
Fax Number	:	866-591-0740

Provider Business Practice Location Address
First Line	:	220 71ST ST
Second Line	:	STE 217
City	:	MIAMI BEACH
State	:	FL
Zip	:	33141-3295
Country	:	US
Telephone Number	:	786-333-0844
Fax Number	:	866-591-0740

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MADELYN ENRIQUEZ
Credential	:
Telephone Number	:	786-333-0844

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	07/16/2010

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