Provider Demographics
NPI:1457565780
Name:EVERGREEN HEALTHCARE SERVICES, INC.
Entity Type:Organization
Organization Name:EVERGREEN HEALTHCARE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:N
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:330-652-3355
Mailing Address - Street 1:EVERGREEN HEALTHCARE SERVICES, INC.
Mailing Address - Street 2:PO BOX 221
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446
Mailing Address - Country:US
Mailing Address - Phone:330-652-3355
Mailing Address - Fax:330-652-1477
Practice Address - Street 1:609 VIENNA AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446
Practice Address - Country:US
Practice Address - Phone:330-652-3355
Practice Address - Fax:330-652-1477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2437643251B00000X, 251G00000X, 343900000X
PA0019704300003251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No251B00000XAgenciesCase Management
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019704300003Medicaid
OH2434376Medicaid