Organization
EVERGREEN CONVALESCENT HOSPITAL AND REHABILITATION CENTER, INC.
Active
Other names
Evergreen Nursing & Rehabilitation Care Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BENEDICT V. CIPPONERI JR. (CHIEF EXECUTIVE OFFICER)
(209) 577-1055
Entity
Organization
Contact information
Practice address
2030 EVERGREEN AVE, MODESTO, CA 95350-3785
(209) 577-1055
(209) 550-3619
Mailing address
2030 EVERGREEN AVE, MODESTO, CA 95350-3785
(209) 577-1055
(209) 550-3619
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
100000038
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
13676588
STATE-COMP
CA
05
—
ZZR55118F
—
CA
Enumeration date
07/07/2005
Last updated
05/21/2013
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