1881763373 NPI number — EVERGREEN EYE CENTER, PLLC

Table of content: (NPI 1881763373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881763373 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:
1881763373
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:
34719 6TH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98003-8714
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:
2820 GRIFFIN AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENUMCLAW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98022-2373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-802-4549
Provider Business Practice Location Address Fax Number:
360-825-8354
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAMPOS
Authorized Official First Name:
ROSA
Authorized Official Middle Name:
ANGELICA
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: 891451 . This is a "CRIME VICS ENUMCLAW EEC" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: WA0527 . This is a "NBN" 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".
  • Identifier: 7080781 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EV8144 . This is a "KCM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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