Basic Information
| Provider Information | |||||||||
| NPI: | 1699962365 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN HOME HEALTHCARE, LLC. | ||||||||
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| OtherOrganizationName: | AVEANNA HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 INTERSTATE NORTH PKWY SE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704411580 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 N HOWES ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805212012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704166481 | ||||||||
| FaxNumber: | 9702260290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | STRANGE | ||||||||
| AuthorizedOfficialFirstName: | HARMON | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4704648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | N | Agencies | In Home Supportive Care | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 96136260 | 05 | CO | MEDICAID |