Basic Information
| Provider Information | |||||||||
| NPI: | 1083662514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN AT GARDNERVILLE, L.L.C. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GARDNERVILLE HEALTH & REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 NE 77TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986626736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608926628 | ||||||||
| FaxNumber: | 3608825793 | ||||||||
| Practice Location | |||||||||
| Address1: | 1573 MULLER PKWY | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894107918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757826620 | ||||||||
| FaxNumber: | 7757826945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO AND ASSISTANT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3608926628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMPRES NEVADA HEALTHCARE, LLC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 314000000X | 3995SNF-5 | NV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100503498 | 05 | NV | MEDICAID |