Provider Demographics
NPI:1245237965
Name:EVERGREEN CONVALESCENT HOSPITAL AND REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:EVERGREEN CONVALESCENT HOSPITAL AND REHABILITATION CENTER, INC.
Other - Org Name:EVERGREEN NURSING & REHABILITATION CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENEDICT
Authorized Official - Middle Name:V
Authorized Official - Last Name:CIPPONERI
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:209-577-1055
Mailing Address - Street 1:2030 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-3785
Mailing Address - Country:US
Mailing Address - Phone:209-577-1055
Mailing Address - Fax:209-550-3619
Practice Address - Street 1:2030 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3785
Practice Address - Country:US
Practice Address - Phone:209-577-1055
Practice Address - Fax:209-550-3619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000038314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13676588OtherSTATE-COMP
CAZZR55118FMedicaid
CAZZR55118FMedicaid
CA555118Medicare Oscar/Certification