MEDICARE: EVERGREEN WASHINGTON HEALTHCARE ENUMCLAW, L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	NH1266	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457346785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN WASHINGTON HEALTHCARE ENUMCLAW, L.L.C.

Provider Business Mailing Address
First Line	:	4601 NE 77TH AVE
Second Line	:	SUITE 300
City	:	VANCOUVER
State	:	WA
Zip	:	98662-6736
Country	:	US
Telephone Number	:	360-892-6628
Fax Number	:	360-882-5793

Provider Business Practice Location Address
First Line	:	2323 JENSEN ST
Second Line	:
City	:	ENUMCLAW
State	:	WA
Zip	:	98022-3698
Country	:	US
Telephone Number	:	360-825-2541
Fax Number	:	360-825-4351

Authorized Official
Title or Position	:	CFO AND ASSISTANT MANAGER
Name	:	MICHAEL J. MILLER
Credential	:
Telephone Number	:	360-892-6628

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	02/02/2022

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