Provider Demographics
NPI:1538122031
Name:EVERGREEN TERRACE LLC
Entity Type:Organization
Organization Name:EVERGREEN TERRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIMBELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-232-9573
Mailing Address - Street 1:1625 SIMMS ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-2611
Mailing Address - Country:US
Mailing Address - Phone:303-238-8161
Mailing Address - Fax:303-238-2714
Practice Address - Street 1:1625 SIMMS ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-2611
Practice Address - Country:US
Practice Address - Phone:303-238-8161
Practice Address - Fax:303-238-2714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0573313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05523532Medicaid