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
—
—
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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