MEDICARE: EVERGREEN ESTATES NURSING & REHABILITATION CENTER LLC

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
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1255049797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN ESTATES NURSING & REHABILITATION CENTER LLC

Provider Business Mailing Address
First Line	:	10401 LINN STATION RD STE 300
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-3825
Country	:	US
Telephone Number	:	270-336-1050
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 EVERGREEN RD
Second Line	:
City	:	WOODBURN
State	:	OR
Zip	:	97071-2910
Country	:	US
Telephone Number	:	503-982-0111
Fax Number	:	503-982-2481

Authorized Official
Title or Position	:	CEO
Name	:	DONALD J. KNOX
Credential	:
Telephone Number	:	740-359-5401

Provider Enumeration Date	:	11/14/2022
Last Update Date	:	01/02/2025

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