1104874239 NPI number — EVERGREEN AT FULLERTON, L.L.C.

Table of content: (NPI 1104874239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104874239 NPI number — EVERGREEN AT FULLERTON, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN AT FULLERTON, 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:
Provider Other Organization Name Type Code:
6
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:
1104874239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2222 N HARBOR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FULLERTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92835-2605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-992-5701
Provider Business Mailing Address Fax Number:
714-526-4884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2222 N HARBOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92835-2605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-992-5701
Provider Business Practice Location Address Fax Number:
714-526-4884
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PATTERSON
Authorized Official First Name:
DALE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
360-892-6628

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  060000205 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LTC55532F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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