Organization
EVERGREEN EYE CENTER, PLLC
Active
Organization
EVERGREEN EYE CENTER, PLLC
Active
Other names
Evergreen Eye Center
Organization subpart
No
Provider details
NPI number
Authorized official
ROSA ANGELICA CAMPOS (CREDENTIALING MANAGER)
(206) 215-2004
Entity
Organization
Contact information
Practice address
15153 5TH AVE SW, BURIEN, WA 98166-3072
(800) 340-3595
(855) 929-1515
Mailing address
15153 5TH AVE SW, BURIEN, WA 98166-3072
(206) 212-2100
(206) 212-2174
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
207W00000X
Ophthalmology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0870427
AETNA
WA
05
—
2017242
—
WA
01
—
59460
L&I
WA
05
—
7080781
—
WA
01
—
891451
CRIME VICTIMS
WA
01
—
EV8144
KCM
WA
01
—
P04799
PCMB
WA
01
—
WA0527
NBN
WA
Enumeration date
11/07/2006
Last updated
01/12/2024
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