Provider Demographics
NPI:1689840050
Name:EVERGREENHEALTH AND REHAB
Entity Type:Organization
Organization Name:EVERGREENHEALTH AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OCCUPATIONAL THERAPY ASSI
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:KULFAN
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:360-689-5673
Mailing Address - Street 1:7680 VINEYARDS LN NE APT K302
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-9255
Mailing Address - Country:US
Mailing Address - Phone:360-689-5673
Mailing Address - Fax:
Practice Address - Street 1:3517 11TH ST
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-2633
Practice Address - Country:US
Practice Address - Phone:360-475-0745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC00001206314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility