Provider Demographics
NPI:1942743869
Name:EMPRES AT DEER LODGE, LLC
Entity Type:Organization
Organization Name:EMPRES AT DEER LODGE, LLC
Other - Org Name:DEER LODGE HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIL
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 1:1100 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722-1829
Practice Address - Country:US
Practice Address - Phone:406-846-1655
Practice Address - Fax:406-846-2602
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMPRES MONTANA HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-25
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT275134Medicare Oscar/Certification