1861876203 NPI number — EVERGREEN OPTOMETRY LLC

Table of content: (NPI 1861876203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861876203 NPI number — EVERGREEN OPTOMETRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN OPTOMETRY 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:
Provider Other Organization Name Type Code:
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:
1861876203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2811 W 10TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-3104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2811 W 10TH AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-3104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-734-2511
Provider Business Practice Location Address Fax Number:
509-734-1632
Provider Enumeration Date:
07/15/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CHONG
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
509-734-2511

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD60369639 , 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)





Copyright © 2007-2025 www.npivalidator.com