=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689840050
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREENHEALTH AND REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2008
-----------------------------------------------------
Last Update Date | 05/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3517 11TH ST
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98312-2633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-475-0745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7680 VINEYARDS LN NE APT K302
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98311-9255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-689-5673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED OCCUPATIONAL THERAPY ASSI
-----------------------------------------------------
Name | MR. THOMAS GERARD KULFAN
-----------------------------------------------------
Credential | COTA
-----------------------------------------------------
Telephone | 360-689-5673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | OC00001206
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------