Provider Demographics
NPI:1003812181
Name:EVERGREEN HEALTH AND REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:EVERGREEN HEALTH AND REHABILITATION CENTER, LLC
Other - Org Name:EVERGREEN HEALTH AND LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:J
Authorized Official - Last Name:REITERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-220-5560
Mailing Address - Street 1:19933 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1024
Mailing Address - Country:US
Mailing Address - Phone:248-203-9000
Mailing Address - Fax:248-203-9001
Practice Address - Street 1:19933 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1024
Practice Address - Country:US
Practice Address - Phone:248-203-9000
Practice Address - Fax:248-203-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63-4021314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235582Medicare Oscar/Certification