Provider Demographics
NPI:1922391408
Name:EVERGREEN QUALITY HOME
Entity Type:Organization
Organization Name:EVERGREEN QUALITY HOME
Other - Org Name:ADULT FAMILY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROIAL-CRACIUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-885-7933
Mailing Address - Street 1:304 NW 102ND ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-5233
Mailing Address - Country:US
Mailing Address - Phone:360-885-7933
Mailing Address - Fax:360-573-7131
Practice Address - Street 1:304 NW 102ND ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-5233
Practice Address - Country:US
Practice Address - Phone:360-885-7933
Practice Address - Fax:360-573-7131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA654400311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home