Provider Demographics
NPI:1902854755
Name:EVERGREEN AT GRIDLEY SNF, L.L.C.
Entity Type:Organization
Organization Name:EVERGREEN AT GRIDLEY SNF, L.L.C.
Other - Org Name:EVERGREEN GRIDLEY HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NIPP
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 1:246 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:CA
Practice Address - Zip Code:95948-2216
Practice Address - Country:US
Practice Address - Phone:530-846-6266
Practice Address - Fax:530-846-5132
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN CALIFORNIA HEALTHCARE, L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000047314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR18521HMedicaid
CAZZR18521HMedicaid