Healthcare Provider Details

I. General information

NPI: 1740238575
Provider Name (Legal Business Name): EVERGREEN AT CASTRO VALLEY, 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

20259 LAKE CHABOT RD
CASTRO VALLEY CA
94546-5307
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 510-351-3700
  • Fax: 510-889-7955
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 Number
License Number StateCA

VIII. Authorized Official

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