Provider Demographics
NPI:1861688087
Name:EVERGREENS ASSISTED LIVING
Entity Type:Organization
Organization Name:EVERGREENS ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-604-1761
Mailing Address - Street 1:8795 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:JESSUP
Mailing Address - State:MD
Mailing Address - Zip Code:20794-3943
Mailing Address - Country:US
Mailing Address - Phone:301-604-1761
Mailing Address - Fax:301-490-6256
Practice Address - Street 1:8795 MISSION RD
Practice Address - Street 2:
Practice Address - City:JESSUP
Practice Address - State:MD
Practice Address - Zip Code:20794-3943
Practice Address - Country:US
Practice Address - Phone:301-604-1761
Practice Address - Fax:301-490-6256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13AL160385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD783697000Medicaid