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General NPI Number Information
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NPI Number | 1508317223
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Entity Type | Organization
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Legal Business Name | EVERGREEN WOODS RETIREMENT, LLC
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Dates
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Enumeration Date | 10/18/2016
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Last Update Date | 04/26/2017
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Provider Practice Location Address
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Address Line | 88 NOTCH HILL RD
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City | NORTH BRANFORD
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State | CT
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Zip | 06471-1846
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Country | US
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Telephone | 203-488-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 3530 TORINGDON WAY SUITE 204
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City | CHARLOTTE
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State | NC
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Zip | 28277-3431
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Country | US
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Telephone | 704-246-1620
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. DONALD O THOMPSON JR.
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Credential |
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Telephone | 704-246-1620
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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 |
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License Number State |
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