1083662514 NPI number — EVERGREEN AT GARDNERVILLE, L.L.C.

Table of content: (NPI 1083662514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083662514 NPI number — EVERGREEN AT GARDNERVILLE, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN AT GARDNERVILLE, L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GARDNERVILLE HEALTH & REHAB CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083662514
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 NE 77TH AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-6736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-892-6628
Provider Business Mailing Address Fax Number:
360-882-5793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1573 MULLER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDNERVILLE
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89410-7918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-782-6620
Provider Business Practice Location Address Fax Number:
775-782-6945
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CFO AND ASSISTANT MANAGER
Authorized Official Telephone Number:
360-892-6628

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 3995SNF-5 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100503498 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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