Provider Demographics
NPI:1437714888
Name:EVERGREEN HOMECARE SERVICE OF NY INC
Entity Type:Organization
Organization Name:EVERGREEN HOMECARE SERVICE OF NY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:HYUNJONG
Authorized Official - Middle Name:
Authorized Official - Last Name:KOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-321-2113
Mailing Address - Street 1:154-08 NORTHERN BLVD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354
Mailing Address - Country:US
Mailing Address - Phone:718-321-2113
Mailing Address - Fax:718-925-4105
Practice Address - Street 1:154-08 NORTHERN BLVD
Practice Address - Street 2:SUITE 2A
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-321-2113
Practice Address - Fax:718-925-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-01
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04345855Medicaid