Basic Information
| Provider Information | |||||||||
| NPI: | 1538154885 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN AMERICANA HEALTH AND REHABILITATION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 917 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604255910 | ||||||||
| FaxNumber: | 3606365935 | ||||||||
| Practice Location | |||||||||
| Address1: | 917 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604255910 | ||||||||
| FaxNumber: | 3606365935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | JODY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH INFORMATION MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3604255910 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4112231 | 05 | WA | MEDICAID |