# EVERGREEN CONVALESCENT HOSPITAL AND REHABILITATION CENTER, INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Evergreen Nursing & Rehabilitation Care Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1245237965
- **Authorized official:** MR. BENEDICT V. CIPPONERI JR. (CHIEF EXECUTIVE OFFICER)
- **Authorized official phone:** (209) 577-1055

## Contact information

- **Practice address:** 2030 EVERGREEN AVE, MODESTO, CA 95350-3785
- **Practice address phone:** (209) 577-1055
- **Practice address fax:** (209) 550-3619
- **Mailing address:** 2030 EVERGREEN AVE, MODESTO, CA 95350-3785
- **Mailing address phone:** (209) 577-1055
- **Mailing address fax:** (209) 550-3619

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 100000038 | CA | Yes |

## Other

- **Enumeration date:** 07/07/2005
- **Last updated:** 05/21/2013

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 13676588 | STATE-COMP | CA |
| 05 | — | ZZR55118F | — | CA |