Basic Information
| Provider Information | |||||||||
| NPI: | 1457346785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVERGREEN WASHINGTON HEALTHCARE ENUMCLAW, L.L.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ENUMCLAW 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: | 2323 JENSEN ST | ||||||||
| Address2: | |||||||||
| City: | ENUMCLAW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980223698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608252541 | ||||||||
| FaxNumber: | 3608254351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO AND ASSISTANT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3608926628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMPRES WASHINGTON HEALTHCARE, LLC | ||||||||
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| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH1266 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4112660 | 05 | WA | MEDICAID |