Healthcare Provider Details

I. General information

NPI: 1730783788
Provider Name (Legal Business Name): EVERGREEN ISLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 MOUNT DIABLO WAY
LIVERMORE CA
94551-6937
US

IV. Provider business mailing address

52 OBSIDIAN WAY
LIVERMORE CA
94550-9470
US

V. Phone/Fax

Practice location:
  • Phone: 925-518-8464
  • Fax: 925-380-1668
Mailing address:
  • Phone: 925-518-8464
  • Fax: 925-380-1668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS JANELLE M GARCIA
Title or Position: CEO
Credential:
Phone: 925-518-8464