Healthcare Provider Details

I. General information

NPI: 1447703533
Provider Name (Legal Business Name): EVERGREEN AT MISSOULA, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3018 RATTLESNAKE DR
MISSOULA MT
59802-6101
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 406-549-0988
  • Fax: 406-549-0111
Mailing address:
  • Phone: 360-892-6628
  • Fax: 360-882-5793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number13184
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateMT
# 4
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateMT

VIII. Authorized Official

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