Healthcare Provider Details

I. General information

NPI: 1245237965
Provider Name (Legal Business Name): EVERGREEN CONVALESCENT HOSPITAL AND REHABILITATION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 EVERGREEN AVE
MODESTO CA
95350-3785
US

IV. Provider business mailing address

2030 EVERGREEN AVE
MODESTO CA
95350-3785
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-1055
  • Fax: 209-550-3619
Mailing address:
  • Phone: 209-577-1055
  • Fax: 209-550-3619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100000038
License Number StateCA

VIII. Authorized Official

Name: MR. BENEDICT V. CIPPONERI JR.
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 209-577-1055