Healthcare Provider Details

I. General information

NPI: 1750339131
Provider Name (Legal Business Name): EVERGREEN AT ELY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 AVENUE G
ELY NV
89301-2539
US

IV. Provider business mailing address

1500 AVENUE G
ELY NV
89301-2539
US

V. Phone/Fax

Practice location:
  • Phone: 775-289-8801
  • Fax: 775-289-3208
Mailing address:
  • Phone: 775-289-8801
  • Fax: 775-289-3208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1218SNF-20
License Number StateNV

VIII. Authorized Official

Name: JAMES ROBERT PREIMESBERGER
Title or Position: MANAGER
Credential:
Phone: 213-220-4808