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NPI Code Detail

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

MEDICARE: EVERGREEN AT CLANCY, 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 Facility9261MT

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 : 1841248242
Entity Type Code : Organization
Provider Name (Legal Business Name) : EVERGREEN AT CLANCY, 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 : 260-882-5793
Provider Business Practice Location Address
First Line : 474 HIGHWAY 282
Second Line :
City : CLANCY
State : MT
Zip : 59634-9519
Country : US
Telephone Number : 406-933-8311
Fax Number : 406-933-8391
Authorized Official
Title or Position : MANAGER
Name : ANDREW V MARTINI
Credential :
Telephone Number : 360-892-6628
Provider Enumeration Date : 05/05/2006
Last Update Date : 08/22/2020

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