Provider Demographics
NPI:1891547717
Name:EVERGREEN ADULT HOME CARE AT TUSTIN LLC
Entity Type:Organization
Organization Name:EVERGREEN ADULT HOME CARE AT TUSTIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-893-0859
Mailing Address - Street 1:14611 DANBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6648
Mailing Address - Country:US
Mailing Address - Phone:951-893-0859
Mailing Address - Fax:
Practice Address - Street 1:14611 DANBERRY CIR
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6648
Practice Address - Country:US
Practice Address - Phone:951-893-0859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility