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General NPI Number Information
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NPI Number | 1316939861
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Entity Type | Organization
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Legal Business Name | EVERGREEN CARE CENTER LLC
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Dates
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Enumeration Date | 08/19/2005
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Last Update Date | 05/27/2015
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Provider Practice Location Address
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Address Line | 1250 S EVERGREEN ST
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City | SHAWANO
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State | WI
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Zip | 54166-3514
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Country | US
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Telephone | 715-526-3107
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Fax | 715-524-8037
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Provider Business Mailing Address
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Address Line | 1726 N BALLARD RD
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City | APPLETON
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State | WI
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Zip | 54911-2444
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Country | US
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Telephone | 920-991-9072
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Fax | 920-749-4021
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Authorized Official
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Title or Position | CFO
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Name | ROBERT M PARKINS
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Credential |
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Telephone | 920-364-9754
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 2896
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License Number State | WI
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