=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497703896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN AT LIVINGSTON, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2006
-----------------------------------------------------
Last Update Date | 06/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 S 14TH ST
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59047-3731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-222-0672
-----------------------------------------------------
Fax | 406-222-1406
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4601 NE 77TH AVE SUITE 300
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98662-6736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-892-6628
-----------------------------------------------------
Fax | 360-882-5793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO AND MANAGER
-----------------------------------------------------
Name | BRENT WEIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-892-6628
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 1858
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number | 316
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | 3188
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 10232
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------