Provider Demographics
NPI:1073919783
Name:EVERGREEN SENIOR LIVING,INC
Entity Type:Organization
Organization Name:EVERGREEN SENIOR LIVING,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHIMIPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-331-2320
Mailing Address - Street 1:23635 COLLINS ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-5916
Mailing Address - Country:US
Mailing Address - Phone:818-331-2320
Mailing Address - Fax:818-704-7339
Practice Address - Street 1:23635 COLLINS ST
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-5916
Practice Address - Country:US
Practice Address - Phone:818-331-2320
Practice Address - Fax:818-704-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197608576310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility