Healthcare Provider Details

I. General information

NPI: 1467519538
Provider Name (Legal Business Name): EVERGREEN RESIDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 KINGS CT
RENO NV
89503-3521
US

IV. Provider business mailing address

1305 KINGS CT
RENO NV
89503-3521
US

V. Phone/Fax

Practice location:
  • Phone: 775-787-9520
  • Fax: 775-747-7417
Mailing address:
  • Phone: 775-787-9520
  • Fax: 775-747-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number3275AGC-6
License Number StateNV

VIII. Authorized Official

Name: MRS. AMEI WOO
Title or Position: ADMINISTRATOR
Credential:
Phone: 775-787-9520