1821167479 NPI number — EVERGREEN EYE CENTER, PLLC

Table of content: (NPI 1821167479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821167479 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:
1821167479
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:
206-212-2171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34719 6TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-8714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-212-2100
Provider Business Practice Location Address Fax Number:
206-212-2174
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: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 490003159 . This is a "RAILROAD MEDICARE ASC NUM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7081250 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EV5682 . This is a "REGENCE ASC NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P06705 . This is a "PCMB ASC NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 111881 . This is a "L&I ASC NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: NBN . This is a "WA0527" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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