Provider Demographics
NPI:1992855316
Name:EVERGREEN MANOR SENIOR CARE CENTRE, LLC
Entity Type:Organization
Organization Name:EVERGREEN MANOR SENIOR CARE CENTRE, LLC
Other - Org Name:EVERGREEN SENIOR CARE AND REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:SANGSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-534-0150
Mailing Address - Street 1:10503 CITATION DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-6551
Mailing Address - Country:US
Mailing Address - Phone:810-534-0150
Mailing Address - Fax:810-534-0208
Practice Address - Street 1:111 EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MI
Practice Address - Zip Code:49037-7417
Practice Address - Country:US
Practice Address - Phone:269-969-6110
Practice Address - Fax:269-969-6710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI134160314000000X, 332BN1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4406078Medicaid
MI09903OtherBCBSM
MI0A30320OtherBCBS DME P&O
MI09903OtherBCBSM
MI235054Medicare Oscar/Certification