Provider Demographics
NPI:1083264709
Name:EVERGREEN HOMECARE SERVICES
Entity Type:Organization
Organization Name:EVERGREEN HOMECARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSSESSOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JISOOK
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-968-2655
Mailing Address - Street 1:513 WATERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-6617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:513 WATERVIEW DR
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-6617
Practice Address - Country:US
Practice Address - Phone:917-968-2655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-14
Last Update Date:2019-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care