Provider Demographics
NPI:1477540193
Name:EVERGREEN VALLEY NURSING HOME
Entity Type:Organization
Organization Name:EVERGREEN VALLEY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EPHRAIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAGELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-597-7600
Mailing Address - Street 1:8 BUSHEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MORRISONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12901-3785
Mailing Address - Country:US
Mailing Address - Phone:518-563-3261
Mailing Address - Fax:518-562-1367
Practice Address - Street 1:8 BUSHEY BLVD.
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-3785
Practice Address - Country:US
Practice Address - Phone:518-563-3261
Practice Address - Fax:518-562-1367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0901301N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00308801Medicaid
NY02329757Medicaid
NY00308801Medicaid