Provider Demographics
NPI:1144213281
Name:EVERGREEN RETIREMENT COMMUNITY, INC.
Entity Type:Organization
Organization Name:EVERGREEN RETIREMENT COMMUNITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH CENTER ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:F
Authorized Official - Last Name:BELLIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:920-237-6200
Mailing Address - Street 1:1130 N WESTFIELD ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-3217
Mailing Address - Country:US
Mailing Address - Phone:920-233-2340
Mailing Address - Fax:920-237-2109
Practice Address - Street 1:1130 N WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-3217
Practice Address - Country:US
Practice Address - Phone:920-233-2340
Practice Address - Fax:920-237-2109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2057314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20136400Medicaid
WI20136400Medicaid