Basic Information
Provider Information | |||||||||
NPI: | 1104874940 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EVERGREEN AT PETALUMA, L.L.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EMPRES POST ACUTE REHABILITATION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4601 NE 77TH AVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986626729 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608926628 | ||||||||
FaxNumber: | 3608825793 | ||||||||
Practice Location | |||||||||
Address1: | 300 DOUGLAS ST | ||||||||
Address2: |   | ||||||||
City: | PETALUMA | ||||||||
State: | CA | ||||||||
PostalCode: | 949522503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7077636887 | ||||||||
FaxNumber: | 7077630314 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 01/30/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEIL | ||||||||
AuthorizedOfficialFirstName: | BRENT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO AND MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3608926628 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EMPRES CALIFORNIA HEALTHCARE, L.L.C. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 010000018 | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | ZZRO6120J | 05 | CA |   | MEDICAID |