1093763419 NPI number — EVERGREEN AT POLSON, L.L.C.

Table of content: (NPI 1093763419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093763419 NPI number — EVERGREEN AT POLSON, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN AT POLSON, 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:
POLSON HEALTH AND REHABILITATION 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:
1093763419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2021
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:
9 14TH AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POLSON
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59860-5321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-883-4378
Provider Business Practice Location Address Fax Number:
406-883-3388
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEIL
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO AND MANAGER
Authorized Official Telephone Number:
360-892-6628

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0700X , with the licence number: 3111 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0700X , with the licence number: 3582 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 10145 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 310622 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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