Provider Demographics
NPI:1366697153
Name:EVERGREEN MANOR RETIREMENT HOME
Entity type:Organization
Organization Name:EVERGREEN MANOR RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:YEE-CHUN
Authorized Official - Middle Name:TAN
Authorized Official - Last Name:KAPUSINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:727-480-2180
Mailing Address - Street 1:3297 STATE ROAD 580
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-4929
Mailing Address - Country:US
Mailing Address - Phone:727-724-3776
Mailing Address - Fax:
Practice Address - Street 1:3297 STATE ROAD 580
Practice Address - Street 2:
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-4929
Practice Address - Country:US
Practice Address - Phone:727-724-3776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8760310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherFEDERAL ID NUMBER