Healthcare Provider Details

I. General information

NPI: 1316033152
Provider Name (Legal Business Name): EVERGREEN VALLEY NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 BUSHEY BLVD
PLATTSBURGH NY
12901-3761
US

IV. Provider business mailing address

8 BUSHEY BLVD
PLATTSBURGH NY
12901-3761
US

V. Phone/Fax

Practice location:
  • Phone: 518-563-3261
  • Fax: 518-562-1367
Mailing address:
  • Phone: 518-563-3261
  • Fax: 518-562-1367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number0901301N
License Number StateNY

VIII. Authorized Official

Name: MICHELE BYNO
Title or Position: ADMINISTRATOR
Credential:
Phone: 518-563-3261