Provider Demographics
NPI:1407885197
Name:EVERGREEN VISION CORP.
Entity Type:Organization
Organization Name:EVERGREEN VISION CORP.
Other - Org Name:EVERGREEN VISION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:PM
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-329-5700
Mailing Address - Street 1:412 12TH AVE S
Mailing Address - Street 2:#205
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2032
Mailing Address - Country:US
Mailing Address - Phone:206-329-5700
Mailing Address - Fax:206-329-4894
Practice Address - Street 1:412 12TH AVE S
Practice Address - Street 2:#205
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2032
Practice Address - Country:US
Practice Address - Phone:206-329-5700
Practice Address - Fax:206-329-4894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2089152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020337Medicaid
WAU39930Medicare UPIN