Provider Demographics
NPI:1184689408
Name:EVERGREEN EYE CENTER, PLLC
Entity type:Organization
Organization Name:EVERGREEN EYE CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:WHAKUK
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-212-2100
Mailing Address - Street 1:1101 MADISON ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1306
Mailing Address - Country:US
Mailing Address - Phone:206-215-2004
Mailing Address - Fax:206-215-2055
Practice Address - Street 1:1455 NW LEARY WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5136
Practice Address - Country:US
Practice Address - Phone:206-342-6041
Practice Address - Fax:206-781-8693
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE ASSOCIATES NORTHWEST, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-19
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALABOR & INDUSTRIESOther0014585
WA7094410Medicaid
WAGAB09665Medicare PIN