1811208077 NPI number — EVERGREEN HEALTH CARE CENTER, LLC

Table of content: (NPI 1811208077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811208077 NPI number — EVERGREEN HEALTH CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN HEALTH CARE CENTER, LLC
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:
Provider Other Organization Name Type Code:
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:
1811208077
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 MOLTKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCRANTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18505-2886
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-969-2188
Provider Business Mailing Address Fax Number:
570-969-2189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 CLAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18510-1759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-344-2800
Provider Business Practice Location Address Fax Number:
570-344-1977
Provider Enumeration Date:
06/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-969-2188

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  133802 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1024773960001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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