Provider Demographics
NPI:1902615966
Name:EVERGREEN PATHWAYS HOME LLC
Entity type:Organization
Organization Name:EVERGREEN PATHWAYS HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAILA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-230-7005
Mailing Address - Street 1:3500 GROVE CITY RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-2598
Mailing Address - Country:US
Mailing Address - Phone:614-230-7005
Mailing Address - Fax:
Practice Address - Street 1:3500 GROVE CITY RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-2598
Practice Address - Country:US
Practice Address - Phone:614-230-7005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-04
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Single Specialty