Provider Demographics
NPI:1427006220
Name:EVERGREEN AT SHELTON, L.L.C.
Entity Type:Organization
Organization Name:EVERGREEN AT SHELTON, L.L.C.
Other - Org Name:SHELTON HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
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:98662-6736
Mailing Address - Country:US
Mailing Address - Phone:360-892-6628
Mailing Address - Fax:360-882-5793
Practice Address - Street 1:153 JOHNS CT
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-8225
Practice Address - Country:US
Practice Address - Phone:360-427-2575
Practice Address - Fax:360-427-2563
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMPRES WASHINGTON HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-04
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1324314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4113247Medicaid
WA4113247Medicaid