Provider Demographics
NPI:1518301902
Name:EVERGREEN HOSPICE LLC
Entity Type:Organization
Organization Name:EVERGREEN HOSPICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-753-2438
Mailing Address - Street 1:1355 N MAIN STREET, STE 11
Mailing Address - Street 2:EVERGREEN HOSPICE DBA RENEW HOME HEALTH & HOSPICE
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-5982
Mailing Address - Country:US
Mailing Address - Phone:801-364-4250
Mailing Address - Fax:801-994-1278
Practice Address - Street 1:1355 N MAIN ST STE 11
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5982
Practice Address - Country:US
Practice Address - Phone:801-364-4250
Practice Address - Fax:801-994-1278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2013-HOSPICE-UT00058251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT461613Medicare Oscar/Certification