Basic Information
| Provider Information | |||||||||
| NPI: | 1093763419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVERGREEN AT POLSON, L.L.C. | ||||||||
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| OtherOrganizationName: | POLSON HEALTH AND REHABILITATION 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: | 9 14TH AVE W | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598605321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068834378 | ||||||||
| FaxNumber: | 4068833388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | WEIL | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO AND MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3608926628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMPRES MONTANA HEALTHCARE, LLC | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 261QH0700X | 3111 | MT | N | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 261QH0700X | 3582 | MT | N | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 314000000X | 10145 | MT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 310622 | 05 | MT | MEDICAID |