1053427609 NPI number — JOHNSON EVERGREEN CORPORATION

Table of content: (NPI 1053427609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053427609 NPI number — JOHNSON EVERGREEN CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNSON EVERGREEN CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVERGREEN HEALTH CARE CENTER
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053427609
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 CHESTNUT HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAFFORD SPRINGS
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06076-4005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-684-8714
Provider Business Mailing Address Fax Number:
860-684-8723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 CHESTNUT HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAFFORD SPRINGS
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06076-4005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-684-8714
Provider Business Practice Location Address Fax Number:
860-684-8723
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROMANOWSKI
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF REIMBURSEMENT
Authorized Official Telephone Number:
860-684-8714

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2081-C , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 712385 . This is a "CONNECTICARE PROVIDER NUM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 44044 . This is a "WELLCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: A3796830 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 000020529 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 833 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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