Provider Demographics
NPI:1750496667
Name:EVERGREEN HOME CARE LTD
Entity Type:Organization
Organization Name:EVERGREEN HOME CARE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:847-470-9280
Mailing Address - Street 1:6041 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2943
Mailing Address - Country:US
Mailing Address - Phone:847-470-9280
Mailing Address - Fax:847-470-9928
Practice Address - Street 1:6041 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053
Practice Address - Country:US
Practice Address - Phone:847-470-9280
Practice Address - Fax:847-470-9282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-09-30
Deactivation Date:2018-11-30
Deactivation Code:
Reactivation Date:2018-12-08
Provider Licenses
StateLicense IDTaxonomies
IL1010796251E00000X
IL253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL147888Medicare Oscar/Certification