Provider Demographics
NPI:1487164505
Name:EVERGREEN PLACE LLC
Entity type:Organization
Organization Name:EVERGREEN PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:GUSTAVO
Authorized Official - Last Name:GONZALEZ VILLARRUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-921-0070
Mailing Address - Street 1:PO BOX 9193
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-9193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3481 W 3100 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-2559
Practice Address - Country:US
Practice Address - Phone:801-921-0070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:82230602
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility