MEDICARE: EMPRES AT DEER LODGE, LLC

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		MT

General Provider Information

NPI Number	:	1942743869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPRES AT DEER LODGE, LLC

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

Provider Business Practice Location Address
First Line	:	1100 TEXAS AVE
Second Line	:
City	:	DEER LODGE
State	:	MT
Zip	:	59722-1829
Country	:	US
Telephone Number	:	406-846-1655
Fax Number	:	406-846-2602

Authorized Official
Title or Position	:	CEO AND MANAGER
Name	:	BRENT WEIL
Credential	:
Telephone Number	:	360-892-6628

Provider Enumeration Date	:	11/25/2016
Last Update Date	:	01/30/2017

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