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General NPI Number Information
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NPI Number | 1316995152
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Entity Type | Organization
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Legal Business Name | EVERGREEN AT TRACY, L.L.C.
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Dates
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Enumeration Date | 05/04/2006
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Last Update Date | 01/30/2017
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Provider Practice Location Address
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Address Line | 2586 BUTHMANN AVE
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City | TRACY
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State | CA
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Zip | 95376-2165
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Country | US
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Telephone | 209-832-2273
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Fax | 209-832-0743
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Provider Business Mailing Address
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Address Line | 4601 NE 77TH AVE SUITE 300
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City | VANCOUVER
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State | WA
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Zip | 98662-6736
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Country | US
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Telephone | 360-892-6628
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Fax | 360-882-5793
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Authorized Official
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Title or Position | CEO AND MANAGER
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Name | BRENT WEIL
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Credential |
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Telephone | 360-892-6628
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 100000285
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License Number State | CA
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