1689655334 NPI number — EVERGREEN SURGERY CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689655334 NPI number — EVERGREEN SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN SURGERY CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVERGREEN SURGICAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689655334
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12333 NE 130TH LN
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
KIRKLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98034-7467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-899-5656
Provider Business Mailing Address Fax Number:
425-899-5638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12333 NE 130TH LN
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
KIRKLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98034-7467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-899-5656
Provider Business Practice Location Address Fax Number:
425-899-5638
Provider Enumeration Date:
11/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TOMLIN
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
425-899-5656

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7123631 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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