Evergreen Retirement Community, Inc.

Primary specialty

Home Health AgencyTaxonomy code 251E00000X

License

1186 Issued in WI

Legal business name

EVERGREEN RETIREMENT COMMUNITY, INC.

Doing business as

Evergreen At Home

Practice address

1125 N Westfield St
Oshkosh, WI 54902-3216

Phone

(920) 237-6205

Fax

(920) 966-0334

NPI assigned

Aug 9, 2013

Last updated

Jul 29, 2022By the provider in NPPES

Organization subpart

Yes

Parent organization

EVERGREEN RETIREMENT COMMUNITY, INC.As reported in NPPES

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

Authorized official

Name

Mrs. Peggy Bellin, RN

Title

Administrator

Phone

(920) 237-2140

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Evergreen At Home Doing business as

Medicare fee-for-service enrollment

Enrolled in WI

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1588097810. Details of each certification follow.

• CCN 527321 Home health agency · Active · Details

Home health agency certification: CCN 527321

Legal name

EVERGREEN RETIREMENT COMMUNITY INC

Doing business as

EVERGREEN AT HOME

Certification status

Active

Provider type (POS)

Home health agency

Participating since

Sep 14, 2015

Last certification

Sep 14, 2015

Ownership / control type

Non-Profit

Organization structure

CorporationNon-profit

Incorporated

Mar 1, 1965 in WI

Enrollment address

1125 N Westfield St
Oshkosh, WI 54902-3216

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• Evergreen Retirement Community, Inc.

  • Skilled Nursing Facility
  • Oshkosh, WI
  • NPI 1144213281

  7416963384

  Same PAC ID

Listed as

Evergreen at HomeCCN 527321 · All quality measures

Overall star rating

2.5 of 5

Ownership

Non-Profit

Certified

Sep 14, 2015

Medicare certification status

ActiveFrom the Provider of Services file

Services

Nursing, Medical social, Home health aide, Physical therapy, Speech pathology, Occupational therapy

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

Evergreen Retirement Community Inc2 organizations share this tax ID, including this one

Part of

Evergreen Retirement Community Inc

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Evergreen Retirement Community, Inc.

  • Skilled Nursing Facility
  • Oshkosh, WI
  • NPI 1144213281
  NPD tax ID

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

• Evergreen Retirement Community, Inc.

  • Skilled Nursing Facility
  • Oshkosh, WI
  • NPI 1144213281

  5% Or Greater Direct Ownership Interest, Adp of the SNF, Operational/Managerial Control

  CMS ownership

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

• Evergreen Retirement Community, Inc.

  • Skilled Nursing Facility
  • Oshkosh, WI
  • NPI 1144213281
  NPPES parent name

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

• Ammar Alzoubi, MD

  • Internal Medicine Physician
  • Oshkosh, WI
  • NPI 1598773152

  Home health agency

  Care Compare affiliation
• Eric C Duwell, MD

  • Family Medicine Physician
  • Oshkosh, WI
  • NPI 1710092978

  Home health agency

  Care Compare affiliation
• Teresa H Lee, MD

  • Internal Medicine Physician
  • Oshkosh, WI
  • NPI 1700871209

  Home health agency

  Care Compare affiliation

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

{
    "created_epoch": "1376006400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1659052800000",
    "number": "1588097810",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1125 N WESTFIELD ST",
            "city": "OSHKOSH",
            "state": "WI",
            "postal_code": "549023216",
            "telephone_number": "844-654-7600",
            "fax_number": "920-966-0334"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1125 N WESTFIELD ST",
            "city": "OSHKOSH",
            "state": "WI",
            "postal_code": "549023216",
            "telephone_number": "920-237-6205",
            "fax_number": "920-966-0334"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN RETIREMENT COMMUNITY, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "EVERGREEN RETIREMENT  COMMUNITY, INC.",
        "enumeration_date": "2013-08-09",
        "last_updated": "2022-07-29",
        "certification_date": "2022-07-29",
        "status": "A",
        "authorized_official_last_name": "BELLIN",
        "authorized_official_first_name": "PEGGY",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "920-237-2140",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": "WI",
            "license": "1186",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "527321",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100049268",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen At Home",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Evergreen At Home",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Home Health Agency in Oshkosh, WI
• Providers in Oshkosh, WI by specialty
• Home Health Agency in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 29, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.