1346319852 NPI number — EVERGREEN EYE CENTER, PLLC

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 1346319852 NPI number — EVERGREEN EYE CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN EYE CENTER, PLLC
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:
Provider Other Organization Name Type Code:
6
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:
1346319852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 M ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98002-4586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-212-2100
Provider Business Mailing Address Fax Number:
206-212-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 M ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98002-4586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-340-3595
Provider Business Practice Location Address Fax Number:
855-929-1515
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAMPOS
Authorized Official First Name:
ROSA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
206-215-2004

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 59460 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2017242 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P04799 . This is a "PCMB" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: WA0527 . This is a "NBN AUB" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7080781 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 891451 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: EV8144 . This is a "KCM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0870427 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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