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NPI Code Detail

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

MEDICARE: EVERGREEN AT PETALUMA, 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 Facility010000018CA

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 : 1104874940
Entity Type Code : Organization
Provider Name (Legal Business Name) : EVERGREEN AT PETALUMA, L.L.C.
Provider Business Mailing Address
First Line : 4601 NE 77TH AVE
Second Line : SUITE 300
City : VANCOUVER
State : WA
Zip : 98662-6729
Country : US
Telephone Number : 360-892-6628
Fax Number : 360-882-5793
Provider Business Practice Location Address
First Line : 300 DOUGLAS ST
Second Line :
City : PETALUMA
State : CA
Zip : 94952-2503
Country : US
Telephone Number : 707-763-6887
Fax Number : 707-763-0314
Authorized Official
Title or Position : CEO AND MANAGER
Name : BRENT WEIL
Credential :
Telephone Number : 360-892-6628
Provider Enumeration Date : 05/04/2006
Last Update Date : 01/30/2017

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