NPIMap

Organization Active NPI

Evergreen at Fullerton, L.L.C.

  • Skilled Nursing Facility
  • Fullerton, CA
National Provider Identifier
1104874239
Registry record updated Jan 2, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
060000205 Issued in CA
Legal business name
EVERGREEN AT FULLERTON, L.L.C.
Practice address
2222 N Harbor Blvd
Fullerton, CA 92835-2605
Phone
(714) 992-5701
Fax
(714) 526-4884
NPI assigned
May 4, 2006
Organization subpart
Yes
Parent organization
EMPRES CALIFORNIA HEALTHCARE, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 2, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Dale L. Patterson
Title
Manager
Phone
(360) 892-6628

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 060000205 CA Primary

Addresses

Primary practice location

2222 N Harbor Blvd
Fullerton, CA 92835-2605

Mailing address

2222 N Harbor Blvd
Fullerton, CA 92835-2605
Phone (714) 992-5701

Other identifiers 1

IdentifierTypeStateIssuer
LTC55532FMedicaidCA

Other names 1

  • Fullerton Post Acute Care Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Ability Network2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

2222 N Harbor Blvd
Fullerton, CA 92835
Phone (714) 333-1543

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146700800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1388620800000",
    "number": "1104874239",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2222 N HARBOR BLVD",
            "city": "FULLERTON",
            "state": "CA",
            "postal_code": "928352605",
            "telephone_number": "714-992-5701",
            "fax_number": "714-526-4884"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2222 N HARBOR BLVD",
            "city": "FULLERTON",
            "state": "CA",
            "postal_code": "928352605",
            "telephone_number": "714-992-5701",
            "fax_number": "714-526-4884"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN AT FULLERTON, L.L.C.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "EMPRES CALIFORNIA HEALTHCARE, LLC",
        "enumeration_date": "2006-05-04",
        "last_updated": "2014-01-02",
        "status": "A",
        "authorized_official_last_name": "PATTERSON",
        "authorized_official_first_name": "DALE",
        "authorized_official_middle_name": "L.",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "360-892-6628",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "CA",
            "license": "060000205",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "LTC55532F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fullerton Post Acute Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fullerton, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 2, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.