1922095694 NPI number — EVERGREEN RADIA LLC

Table of content: (NPI 1922095694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922095694 NPI number — EVERGREEN RADIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN RADIA 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 RADIA
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:
1922095694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19020 33RD AVE W STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNNWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98036-4748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-563-1500
Provider Business Mailing Address Fax Number:
425-563-1501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11521 NE 128TH ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
KIRKLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98034-4317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-952-6100
Provider Business Practice Location Address Fax Number:
425-952-6150
Provider Enumeration Date:
09/28/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STAMBAUGH
Authorized Official First Name:
LLOYD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
425-563-1500

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  602317167 , 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: 7118227 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 175238 . This is a "GROUP LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8933574 . This is a "GROUP CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".