Provider Demographics
NPI:1104874239
Name:EVERGREEN AT FULLERTON, L.L.C.
Entity type:Organization
Organization Name:EVERGREEN AT FULLERTON, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
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 1:2222 N HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2605
Mailing Address - Country:US
Mailing Address - Phone:714-992-5701
Mailing Address - Fax:714-526-4884
Practice Address - Street 1:2222 N HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2605
Practice Address - Country:US
Practice Address - Phone:714-992-5701
Practice Address - Fax:714-526-4884
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:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000205314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55532FMedicaid
CA555733Medicare Oscar/Certification