Healthcare Provider Details

I. General information

NPI: 1700700507
Provider Name (Legal Business Name): EVERGREEN GOLDEN AGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 BELMONT TER
MOUNT VERNON WA
98274-4519
US

IV. Provider business mailing address

13525 22ND AVE SE
MILL CREEK WA
98012-5691
US

V. Phone/Fax

Practice location:
  • Phone: 425-900-2848
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: BRANDON LIU
Title or Position: PROVIDER/OWNER
Credential:
Phone: 425-900-2848