Provider Demographics
NPI:1891003554
Name:EVERGREEN IDAHO HEALTHCARE SANDPOINT, L.L.C.
Entity Type:Organization
Organization Name:EVERGREEN IDAHO HEALTHCARE SANDPOINT, L.L.C.
Other - Org Name:SANDOINT ASSISTED LIVING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PATTERSON
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:98662-6729
Mailing Address - Country:US
Mailing Address - Phone:360-892-6628
Mailing Address - Fax:360-882-5793
Practice Address - Street 1:624 S DIVISION AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1749
Practice Address - Country:US
Practice Address - Phone:208-265-2354
Practice Address - Fax:208-263-8787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN IDAHO HEALTHCARE, L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-15
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRC-511310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8055822Medicaid