Provider Demographics
NPI:1073216826
Name:EVERGREEN HOME CARE LLC
Entity Type:Organization
Organization Name:EVERGREEN HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-557-9819
Mailing Address - Street 1:424 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-1916
Mailing Address - Country:US
Mailing Address - Phone:510-557-9819
Mailing Address - Fax:
Practice Address - Street 1:1423A COMPTON RD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94129-2812
Practice Address - Country:US
Practice Address - Phone:510-557-9819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care