Provider Demographics
NPI:1811208077
Name:EVERGREEN HEALTH CARE CENTER, LLC
Entity Type:Organization
Organization Name:EVERGREEN HEALTH CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-969-2188
Mailing Address - Street 1:401 MOLTKE AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2886
Mailing Address - Country:US
Mailing Address - Phone:570-969-2188
Mailing Address - Fax:570-969-2189
Practice Address - Street 1:701 CLAY AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1759
Practice Address - Country:US
Practice Address - Phone:570-344-2800
Practice Address - Fax:570-344-1977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA133802314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024773960001Medicaid
PA1024773960001Medicaid