Provider Demographics
NPI:1881763373
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: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:206-212-2174
Practice Address - Street 1:2820 GRIFFIN AVE STE 101
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2373
Practice Address - Country:US
Practice Address - Phone:360-802-4549
Practice Address - Fax:360-825-8354
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?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA891451OtherCRIME VICS ENUMCLAW EEC
WAWA0527OtherNBN
WA0870427OtherAETNA
WA7080781Medicaid
WAEV8144OtherKCM
WA=========OtherTAX ID
WA2017242Medicare ID - Type UnspecifiedEEC ENUMCLAW OD MEDICARE