Healthcare Provider Details

I. General information

NPI: 1770578791
Provider Name (Legal Business Name): EVERGREEN KITSAP, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3517 11TH ST
BREMERTON WA
98312-2633
US

IV. Provider business mailing address

4601 NE 77TH AVE SUITE 300
VANCOUVER WA
98662-6729
US

V. Phone/Fax

Practice location:
  • Phone: 360-377-5537
  • Fax: 360-405-0537
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 Number1367
License Number StateWA

VIII. Authorized Official

Name: MR. DALE L. PATTERSON
Title or Position: MANAGER
Credential:
Phone: 360-892-6628