NPIMap

Organization Active NPI

Evergreen Hospice Care, Inc.

  • Community Based Hospice Care Agency
  • Cerritos, CA
National Provider Identifier
1629270699
Registry record updated Apr 22, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
License
550000319 Issued in CA
Legal business name
EVERGREEN HOSPICE CARE, INC.
Practice address
17215 Studebaker Rd
Suite 100
Cerritos, CA 90703-2548
Phone
(562) 865-9006
Fax
(562) 865-9022
NPI assigned
Jun 1, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 22, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Lydia Y Ahn, RN, PHN
Title
Administrator
Phone
(562) 865-9006

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X 550000319 CA Primary

Addresses

Primary practice location

17215 Studebaker Rd
Suite 100
Cerritos, CA 90703-2548

Mailing address

17215 Studebaker Rd
Suite 100
Cerritos, CA 90703-2548
Phone (562) 865-9006

Other identifiers 1

IdentifierTypeStateIssuer
1629270699MedicaidCA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040511001829 CA Part A Provider - Hospice 7012906209 Practice locations: Cerritos, CA

Hospice certification: CCN 551530

Legal name
EVERGREEN HOSPICE CARE, INC.
Certification status
Active
Provider type (POS)
Hospice
Participating since
Mar 6, 2008
Last certification
Jun 18, 2021
Ownership / control type
Proprietary - Corporation
Organization structure
CorporationProprietary
Incorporated
Mar 11, 2004 in CA
Enrollment address
17215 Studebaker Rd
Suite #100
Cerritos, CA 90703-2521

Care Compare: Hospice

Medicare Care Compare
Listed as
Evergreen Hospice Care, IncCCN 551530 · All quality measures
Ownership
For-Profit
Certified
Mar 6, 2008
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory

Locations

17215 Studebaker Rd
Ste 100
Cerritos, CA 90703
Phone (562) 865-9006

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Lydia Y Ahn Individual 5% Or Greater Direct Ownership Interest Mar 11, 2004 100%
Corporate OfficerCeo, Secretary, Board Member Mar 11, 2004 98%
Corporate DirectorCeo, Secretary, Board Member Mar 11, 2004 98%
W-2 Managing EmployeeCeo, Secretary, Board Member, Mar 11, 2004 98%
Operational/Managerial ControlCeo, Secretary, Board Member Mar 11, 2004 98%
Felicia Campellone Individual W-2 Managing EmployeeDirector of Patient Care Service Aug 20, 2014 2%
Soumitra Sarkar Individual Contracted Managing EmployeeMedical Director Nov 14, 2007
John J Ahn Individual Corporate OfficerCfo, Board Member Mar 11, 2004 2%
Corporate DirectorCfo, Board Member Mar 11, 2004 2%
W-2 Managing EmployeeCfo, Board Member, Assistant Adm Mar 11, 2004 2%
Operational/Managerial ControlCfo, Board Member, Assistant Adm Mar 11, 2004 2%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1180656000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1303430400000",
    "number": "1629270699",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17215 STUDEBAKER RD",
            "address_2": "SUITE 100",
            "city": "CERRITOS",
            "state": "CA",
            "postal_code": "907032548",
            "telephone_number": "562-865-9006",
            "fax_number": "562-865-9022"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17215 STUDEBAKER RD",
            "address_2": "SUITE 100",
            "city": "CERRITOS",
            "state": "CA",
            "postal_code": "907032548",
            "telephone_number": "562-865-9006",
            "fax_number": "562-865-9022"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN HOSPICE CARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-01",
        "last_updated": "2011-04-22",
        "status": "A",
        "authorized_official_last_name": "AHN",
        "authorized_official_first_name": "LYDIA",
        "authorized_official_middle_name": "Y",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "562-865-9006",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "RN, PHN"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "CA",
            "license": "550000319",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1629270699",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Cerritos, CA

Sources for this page

Verify at the official NPI Registry.