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Organization
EVERGREEN EYE CENTER, PLLC
Active
Organization
EVERGREEN EYE CENTER, PLLC
Active
Other names
Evergreen Eye Surgery Center
Organization subpart
No
Provider details
NPI number
Authorized official
ROSA ANGELICA CAMPOS (CREDENTIALING MANAGER)
(206) 215-2004
Entity
Organization
Contact information
Practice address
34719 6TH AVE S, FEDERAL WAY, WA 98003-8714
(206) 212-2100
(206) 212-2174
Mailing address
34719 6TH AVE S, FEDERAL WAY, WA 98003-8714
(206) 212-2100
(206) 212-2171
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
111881
L&I ASC NUMBER
WA
01
—
490003159
RAILROAD MEDICARE ASC NUM
WA
05
—
7081250
—
WA
01
—
EV5682
REGENCE ASC NUMBER
WA
01
—
NBN
WA0527
WA
01
—
P06705
PCMB ASC NUMBER
WA
Enumeration date
11/07/2006
Last updated
01/12/2024
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