Healthcare Provider Details

I. General information

NPI: 1104874940
Provider Name (Legal Business Name): EVERGREEN AT PETALUMA, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 DOUGLAS ST
PETALUMA CA
94952-2503
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 707-763-6887
  • Fax: 707-763-0314
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 Number010000018
License Number StateCA

VIII. Authorized Official

Name: BRENT WEIL
Title or Position: CEO AND MANAGER
Credential:
Phone: 360-892-6628