Provider Demographics
NPI:1821167479
Name:EVERGREEN EYE CENTER, PLLC
Entity Type:Organization
Organization Name:EVERGREEN EYE CENTER, PLLC
Other - Org Name:EVERGREEN EYE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:ANGELICA
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-215-2004
Mailing Address - Street 1:34719 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8714
Mailing Address - Country:US
Mailing Address - Phone:206-212-2100
Mailing Address - Fax:206-212-2171
Practice Address - Street 1:34719 6TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8714
Practice Address - Country:US
Practice Address - Phone:206-212-2100
Practice Address - Fax:206-212-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA490003159OtherRAILROAD MEDICARE ASC NUM
WA7081250Medicaid
WAEV5682OtherREGENCE ASC NUMBER
WAP06705OtherPCMB ASC NUMBER
WA111881OtherL&I ASC NUMBER
WANBNOtherWA0527
WA=========OtherTAX ID NUMBER ASC
WA217000677Medicare ID - Type UnspecifiedWA STATE MEDICARE NUMBER