Provider Demographics
NPI:1689705022
Name:EVERGREEN MANOR OPT LYNWOOD
Entity Type:Organization
Organization Name:EVERGREEN MANOR OPT LYNWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MS CDP
Authorized Official - Phone:425-258-2407
Mailing Address - Street 1:PO BOX 12598
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206
Mailing Address - Country:US
Mailing Address - Phone:425-258-2407
Mailing Address - Fax:425-339-2601
Practice Address - Street 1:3810 196TH ST SW
Practice Address - Street 2:11
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036
Practice Address - Country:US
Practice Address - Phone:425-248-4900
Practice Address - Fax:425-248-4703
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN MANOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-08
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA31-1336-00261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1995570Medicaid