Healthcare Provider Details

I. General information

NPI: 1497703201
Provider Name (Legal Business Name): EVERGREEN OREGON HEALTHCARE INDEPENDENCE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 MONMOUTH ST
INDEPENDENCE OR
97351-1007
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 503-838-0001
  • Fax: 503-838-7826
Mailing address:
  • Phone: 360-892-6628
  • Fax: 360-882-5793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1663
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier801030
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

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