Provider Demographics
NPI:1871095489
Name:EVERGREEN EYE CENTER, PLLC
Entity type:Organization
Organization Name:EVERGREEN EYE CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:ANGELICA
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-215-2004
Mailing Address - Street 1:1229 MADISON ST STE 1250
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3568
Mailing Address - Country:US
Mailing Address - Phone:206-212-2100
Mailing Address - Fax:206-212-2194
Practice Address - Street 1:1229 MADISON ST STE 1250
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3568
Practice Address - Country:US
Practice Address - Phone:206-212-2100
Practice Address - Fax:206-212-2194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical