MEDICARE: EVERGREEN ADULT MEDICAL DAY CARE

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	261QA0600X	Adult Day Care Clinic/Center	15011A	MD

General Provider Information

NPI Number	:	1932582715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN ADULT MEDICAL DAY CARE

Provider Business Mailing Address
First Line	:	9290 GAITHER RD
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20877-1420
Country	:	US
Telephone Number	:	301-527-1100
Fax Number	:	301-658-3240

Provider Business Practice Location Address
First Line	:	9290 GAITHER RD
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20877-1420
Country	:	US
Telephone Number	:	301-527-1100
Fax Number	:	301-658-3240

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. JADEN JOON KIM
Credential	:
Telephone Number	:	301-527-1100

Provider Enumeration Date	:	06/30/2015
Last Update Date	:	06/30/2015

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