Healthcare Provider Details

I. General information

NPI: 1083662514
Provider Name (Legal Business Name): EVERGREEN AT GARDNERVILLE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1573 MULLER PKWY
GARDNERVILLE NV
89410-7918
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 775-782-6620
  • Fax: 775-782-6945
Mailing address:
  • Phone: 360-892-6628
  • Fax: 360-882-5793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3995SNF-5
License Number StateNV

VIII. Authorized Official

Name: MICHAEL J. MILLER
Title or Position: CFO AND ASSISTANT MANAGER
Credential:
Phone: 360-892-6628