1275581951 NPI number — EVERGREEN AT MESA, L.L.C.

Table of content: (NPI 1275581951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275581951 NPI number — EVERGREEN AT MESA, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN AT MESA, L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVERGREEN VALLEY HEALTH AND REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275581951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 NE 77TH AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-6729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-892-6628
Provider Business Mailing Address Fax Number:
360-882-5793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6458 E BROADWAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-1727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-832-5160
Provider Business Practice Location Address Fax Number:
480-854-7046
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINI
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
V.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
360-892-6628

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NCA-2627 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 748767 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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