Evergreen Convalescent Hospital and Rehabilitation Center, Inc.

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

100000038 Issued in CA

Legal business name

EVERGREEN CONVALESCENT HOSPITAL AND REHABILITATION CENTER, INC.

Doing business as

Evergreen Nursing & Rehabilitation Care Center

Practice address

2030 Evergreen Ave
Modesto, CA 95350-3785

Phone

(209) 577-1055

Fax

(209) 550-3619

NPI assigned

Jul 7, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Benedict V. Cipponeri Jr.

Title

Chief Executive Officer

Phone

(209) 577-1055

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Evergreen Nursing & Rehabilitation Care Center Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1120694400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1369094400000",
    "number": "1245237965",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2030 EVERGREEN AVE",
            "city": "MODESTO",
            "state": "CA",
            "postal_code": "953503785",
            "telephone_number": "209-577-1055",
            "fax_number": "209-550-3619"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2030 EVERGREEN AVE",
            "city": "MODESTO",
            "state": "CA",
            "postal_code": "953503785",
            "telephone_number": "209-577-1055",
            "fax_number": "209-550-3619"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN CONVALESCENT HOSPITAL AND REHABILITATION CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-07",
        "last_updated": "2013-05-21",
        "status": "A",
        "authorized_official_last_name": "CIPPONERI",
        "authorized_official_first_name": "BENEDICT",
        "authorized_official_middle_name": "V.",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "209-577-1055",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "CA",
            "license": "100000038",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE-COMP",
            "identifier": "13676588",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZR55118F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Nursing & Rehabilitation Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Kinnesha Evans, B.A.
• Matthew Shane Evans, CPO
• Rebecca Evans, RN, BSN, PHN
• Kathleen Lynn Eve, MD
• Jamie Everett, BA
• Jahnae Everhart
• Everside-Ca Ironworkers-Modesta
• Evins Cremation &Funeral Home (Evins Funeral Home)
• Tyler Ewing
• Express to Progress Inc.

• Skilled Nursing Facility in Modesto, CA
• Providers in Modesto, CA by specialty
• Skilled Nursing Facility in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.