Healthcare Provider Details

I. General information

NPI: 1053427609
Provider Name (Legal Business Name): JOHNSON EVERGREEN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 CHESTNUT HILL RD
STAFFORD SPRINGS CT
06076-4005
US

IV. Provider business mailing address

205 CHESTNUT HILL RD
STAFFORD SPRINGS CT
06076-4005
US

V. Phone/Fax

Practice location:
  • Phone: 860-684-8714
  • Fax: 860-684-8723
Mailing address:
  • Phone: 860-684-8714
  • Fax: 860-684-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2081-C
License Number StateCT

VIII. Authorized Official

Name: MRS. ANNA ROMANOWSKI
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 860-684-8714