Provider Demographics
NPI:1629270699
Name:EVERGREEN HOSPICE CARE, INC.
Entity Type:Organization
Organization Name:EVERGREEN HOSPICE CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:AHN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, PHN
Authorized Official - Phone:562-865-9006
Mailing Address - Street 1:17215 STUDEBAKER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2548
Mailing Address - Country:US
Mailing Address - Phone:562-865-9006
Mailing Address - Fax:562-865-9022
Practice Address - Street 1:17215 STUDEBAKER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2548
Practice Address - Country:US
Practice Address - Phone:562-865-9006
Practice Address - Fax:562-865-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000319251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629270699Medicaid
CA1629270699Medicaid