Provider Demographics
NPI:1659162402
Name:EVERGREEN HEALTHCARE CLINIC LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:EVERGREEN HEALTHCARE CLINIC LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEDJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-644-5570
Mailing Address - Street 1:13707 CROWNSGATE WAY
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-4424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 INDIAN GRASS CT
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-2930
Practice Address - Country:US
Practice Address - Phone:240-644-5570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty