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NPI Code Detail

MEDICARE: EVERGREEN AT FULLERTON, L.L.C.

MEDICARE: EVERGREEN AT FULLERTON, L.L.C.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing Facility060000205CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1104874239
Entity Type Code : Organization
Provider Name (Legal Business Name) : EVERGREEN AT FULLERTON, L.L.C.
Provider Business Mailing Address
First Line : 2222 N HARBOR BLVD
Second Line :
City : FULLERTON
State : CA
Zip : 92835-2605
Country : US
Telephone Number : 714-992-5701
Fax Number : 714-526-4884
Provider Business Practice Location Address
First Line : 2222 N HARBOR BLVD
Second Line :
City : FULLERTON
State : CA
Zip : 92835-2605
Country : US
Telephone Number : 714-992-5701
Fax Number : 714-526-4884
Authorized Official
Title or Position : MANAGER
Name : MR. DALE L. PATTERSON
Credential :
Telephone Number : 360-892-6628
Provider Enumeration Date : 05/04/2006
Last Update Date : 01/02/2014

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Directions to “EVERGREEN AT FULLERTON, L.L.C. ” Practice Location

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