Healthcare Provider Details

I. General information

NPI: 1093763419
Provider Name (Legal Business Name): EVERGREEN AT POLSON, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 14TH AVE W
POLSON MT
59860-5321
US

IV. Provider business mailing address

4601 NE 77TH AVE SUITE 300
VANCOUVER WA
98662-6736
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-4378
  • Fax: 406-883-3388
Mailing address:
  • Phone: 360-892-6628
  • Fax: 360-882-5793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number3111
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number3582
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10145
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

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