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General NPI Number Information
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NPI Number | 1366697153
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Entity Type | Organization
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Legal Business Name | EVERGREEN MANOR RETIREMENT HOME
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Dates
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Enumeration Date | 11/21/2008
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Last Update Date | 11/21/2008
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Provider Practice Location Address
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Address Line | 3297 STATE ROAD 580
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City | SAFETY HARBOR
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State | FL
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Zip | 34695-4929
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Country | US
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Telephone | 727-724-3776
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Fax |
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Provider Business Mailing Address
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Address Line | 3297 STATE ROAD 580
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City | SAFETY HARBOR
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State | FL
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Zip | 34695-4929
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Country | US
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Telephone | 727-724-3776
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | YEE-CHUN TAN KAPUSINSKY
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Credential | RD
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Telephone | 727-480-2180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL8760
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License Number State | FL
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