Provider Demographics
NPI:1992502595
Name:EVERGREEN SENIOR CARE SERVICE LLC
Entity type:Organization
Organization Name:EVERGREEN SENIOR CARE SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAWEKE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GEBRESELASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-856-2790
Mailing Address - Street 1:9701 S 200TH ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-1442
Mailing Address - Country:US
Mailing Address - Phone:253-856-2790
Mailing Address - Fax:253-981-3156
Practice Address - Street 1:9701 S 200TH ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-1442
Practice Address - Country:US
Practice Address - Phone:253-856-2790
Practice Address - Fax:253-981-3156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-01
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home