Healthcare Provider Details

I. General information

NPI: 1992166565
Provider Name (Legal Business Name): MAYBROOK-C EVERGREEN OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 EVERGREEN MILL RD
HARMONY PA
16037-9141
US

IV. Provider business mailing address

191 EVERGREEN MILL ROAD
HARMONY PA
16037-9141
US

V. Phone/Fax

Practice location:
  • Phone: 724-452-6970
  • Fax:
Mailing address:
  • Phone: 724-452-6970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. MARK NORD
Title or Position: ADMINISTRATOR
Credential:
Phone: 724-452-6970