Provider Demographics
NPI:1053427609
Name:JOHNSON EVERGREEN CORPORATION
Entity type:Organization
Organization Name:JOHNSON EVERGREEN CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-684-8714
Mailing Address - Street 1:205 CHESTNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-4005
Mailing Address - Country:US
Mailing Address - Phone:860-684-8714
Mailing Address - Fax:860-684-8723
Practice Address - Street 1:205 CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-4005
Practice Address - Country:US
Practice Address - Phone:860-684-8714
Practice Address - Fax:860-684-8723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2081-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT712385OtherCONNECTICARE PROVIDER NUM
CT44044OtherWELLCARE
CTA3796830OtherOXFORD
CT000020529Medicaid
CT833OtherANTHEM BLUE CROSS BLUE SHIELD
CT833OtherANTHEM BLUE CROSS BLUE SHIELD