Provider Demographics
NPI:1336686914
Name:EVERGREEN KITSAP, L.L.C.
Entity Type:Organization
Organization Name:EVERGREEN KITSAP, L.L.C.
Other - Org Name:NORTHWOODS LODGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-604-4217
Mailing Address - Street 1:4601 NE 77TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6736
Mailing Address - Country:US
Mailing Address - Phone:360-604-4217
Mailing Address - Fax:
Practice Address - Street 1:2321 NW SCHOLD PL
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9504
Practice Address - Country:US
Practice Address - Phone:360-698-8930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMPRES WASHINGTON HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility