Provider Demographics
NPI:1588097810
Name:EVERGREEN RETIREMENT COMMUNITY, INC.
Entity type:Organization
Organization Name:EVERGREEN RETIREMENT COMMUNITY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:920-237-2140
Mailing Address - Street 1:1125 N WESTFIELD ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-3216
Mailing Address - Country:US
Mailing Address - Phone:844-654-7600
Mailing Address - Fax:920-966-0334
Practice Address - Street 1:1125 N WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-3216
Practice Address - Country:US
Practice Address - Phone:920-237-6205
Practice Address - Fax:920-966-0334
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN RETIREMENT COMMUNITY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-09
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1186251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI527321OtherPTAN
WI100049268Medicaid