- Enrollment id
- O20240212002919
- Enrollment state
- CA
- Provider type code
- 00-06
- Provider type text
- PART A PROVIDER - HOME HEALTH AGENCY
- Npi
- 1053067397
- Multiple npi flag
- N
- Ccn
- 757768
- Associate id
- 4183067648
- Organization name
- EVERGREEN HEALTH CARE SERVICES
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- P
- Address line 1
- 12444 VICTORY BLVD
- Address line 2
- STE 411G
- City
- NORTH HOLLYWOOD
- State
- CA
- Zip code
- 916063199