Provider Demographics
NPI:1023066966
Name:EVERGREEN AT SPRINGS ROAD, L.L.C.
Entity type:Organization
Organization Name:EVERGREEN AT SPRINGS ROAD, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position: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:98662-6736
Mailing Address - Country:US
Mailing Address - Phone:360-892-6628
Mailing Address - Fax:360-882-5793
Practice Address - Street 1:1527 SPRINGS RD
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-5448
Practice Address - Country:US
Practice Address - Phone:707-643-2793
Practice Address - Fax:707-554-2876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMPRES CALIFORNIA HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-04
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000003314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05222JMedicaid
CA055222Medicare Oscar/Certification