Healthcare Provider Details

I. General information

NPI: 1508317223
Provider Name (Legal Business Name): EVERGREEN WOODS RETIREMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 NOTCH HILL RD
NORTH BRANFORD CT
06471-1846
US

IV. Provider business mailing address

3530 TORINGDON WAY SUITE 204
CHARLOTTE NC
28277-3431
US

V. Phone/Fax

Practice location:
  • Phone: 203-488-8000
  • Fax:
Mailing address:
  • Phone: 704-246-1620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD O THOMPSON JR.
Title or Position: CEO
Credential:
Phone: 704-246-1620