Provider Demographics
NPI:1275581951
Name:EVERGREEN AT MESA, L.L.C.
Entity Type:Organization
Organization Name:EVERGREEN AT MESA, L.L.C.
Other - Org Name:EVERGREEN VALLEY HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:V
Authorized Official - Last Name:MARTINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-892-6628
Mailing Address - Street 1:4601 NE 77TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6729
Mailing Address - Country:US
Mailing Address - Phone:360-892-6628
Mailing Address - Fax:360-882-5793
Practice Address - Street 1:6458 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1727
Practice Address - Country:US
Practice Address - Phone:480-832-5160
Practice Address - Fax:480-854-7046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCA-2627314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ748767Medicaid
AZ748767Medicaid