Provider Demographics
NPI:1972834539
Name:EVERGREEN NURSING AND REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:EVERGREEN NURSING AND REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-535-3801
Mailing Address - Street 1:805 AVENUE L
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5114
Mailing Address - Country:US
Mailing Address - Phone:718-535-3801
Mailing Address - Fax:718-338-1019
Practice Address - Street 1:1110 WESTVIEW DR
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:TX
Practice Address - Zip Code:76380-3965
Practice Address - Country:US
Practice Address - Phone:940-889-3176
Practice Address - Fax:940-889-8806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX128590314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014747Medicaid
TX001014747Medicaid