Provider Demographics
NPI:1578915609
Name:EVERGREEN ENRICHMENT CENTER LLC
Entity Type:Organization
Organization Name:EVERGREEN ENRICHMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHUIKUEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-459-6441
Mailing Address - Street 1:9002 QUEENS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4941
Mailing Address - Country:US
Mailing Address - Phone:347-459-6441
Mailing Address - Fax:
Practice Address - Street 1:9002 QUEENS BLVD FL 2
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4941
Practice Address - Country:US
Practice Address - Phone:347-459-6441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251300000X, 251B00000X, 251E00000X, 252Y00000X, 343800000X, 343900000X, 344600000X, 347D00000X, 347E00000X
NY610801425347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No344600000XTransportation ServicesTaxi
No347D00000XTransportation ServicesTrain
No347E00000XTransportation ServicesTransportation Broker