Provider Demographics
NPI:1033502000
Name:EVERGREEN OPTICAL INC.
Entity Type:Organization
Organization Name:EVERGREEN OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-662-4747
Mailing Address - Street 1:351 ORONDO AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2826
Mailing Address - Country:US
Mailing Address - Phone:509-662-4747
Mailing Address - Fax:509-663-5338
Practice Address - Street 1:351 ORONDO AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2826
Practice Address - Country:US
Practice Address - Phone:509-662-4747
Practice Address - Fax:509-663-5338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO 00000833156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1000288Medicaid