Provider Demographics
NPI:1104874940
Name:EVERGREEN AT PETALUMA, L.L.C.
Entity type:Organization
Organization Name:EVERGREEN AT PETALUMA, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:300 DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2503
Practice Address - Country:US
Practice Address - Phone:707-763-6887
Practice Address - Fax:707-763-0314
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMPRES CALIFORNIA HEALTHCARE, L.L.C.
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
CA010000018314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZRO6120JMedicaid
CA056120Medicare Oscar/Certification