# EVERGREEN MANOR SENIOR CARE CENTRE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Evergreen Senior Care and Rehab Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1992855316
- **Authorized official:** TODD SANGSTER (CFO)
- **Authorized official phone:** (810) 534-0150

## Contact information

- **Practice address:** 111 EVERGREEN RD, SPRINGFIELD, MI 49037-7417
- **Practice address phone:** (269) 969-6110
- **Practice address fax:** (269) 969-6710
- **Mailing address:** 10503 CITATION DR STE 100, BRIGHTON, MI 48116-6551
- **Mailing address phone:** (810) 534-0150
- **Mailing address fax:** (810) 534-0208

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 134160 | MI | Yes |
| 332BN1400X | Nursing Facility Supplies (DME) | 134160 | MI | — |

## Other

- **Enumeration date:** 01/10/2007
- **Last updated:** 05/05/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 09903 | BCBSM | MI |
| 01 | — | 0A30320 | BCBS DME P&O | MI |
| 05 | — | 4406078 | — | MI |