Healthcare Provider Details

I. General information

NPI: 1114975810
Provider Name (Legal Business Name): EVERGREEN MESA CHRISTIAN, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W BROWN RD
MESA AZ
85201-3404
US

IV. Provider business mailing address

4601 NE 77TH AVE SUITE 300
VANCOUVER WA
98662-6729
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-3988
  • Fax: 480-833-7122
Mailing address:
  • Phone: 360-892-6628
  • Fax: 360-882-5793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNCI-2629
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier748791
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name: MR. ANDREW V. MARTINI
Title or Position: MANAGER
Credential:
Phone: 360-892-6628