NPIMap

Organization Active NPI

Evergreen Eye Center, PLLC

  • Ambulatory Surgical Clinic/Center
  • Tacoma, WA
National Provider Identifier
1104465012
Registry record updated Jan 12, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
Legal business name
EVERGREEN EYE CENTER, PLLC
Practice address
502 S M St
Tacoma, WA 98405-3728
Phone
(800) 340-3595
NPI assigned
Dec 26, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 12, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Rosa Campos
Title
Credentialing Manager
Phone
(206) 215-2004

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ambulatory Surgical Clinic/Center 261QA1903X Primary

Addresses

Primary practice location

502 S M St
Tacoma, WA 98405-3728

Mailing address

502 S M St
Tacoma, WA 98405-3728
Phone (206) 260-2503

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200219002868 WA Part B Supplier - Ambulatory Surgical Center 3173410057 Practice locations: Tacoma, WA

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Ambulatory surgical center

Medicare Care Compare
Listed as
Evergreen Eye CenterCCN 50C0001328
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
Evergreen Eye Surgery C11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the National Provider Directory.

Locations

502 S M St
Tacoma, WA 98405
Phone (253) 301-4953

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1577318400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705017600000",
    "number": "1104465012",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "502 S M ST",
            "city": "TACOMA",
            "state": "WA",
            "postal_code": "984053728",
            "telephone_number": "206-260-2503",
            "fax_number": "855-929-1515"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "502 S M ST",
            "city": "TACOMA",
            "state": "WA",
            "postal_code": "984053728",
            "telephone_number": "800-340-3595"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN EYE CENTER, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-26",
        "last_updated": "2024-01-12",
        "certification_date": "2024-01-12",
        "status": "A",
        "authorized_official_last_name": "CAMPOS",
        "authorized_official_first_name": "ROSA",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "206-215-2004"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tacoma, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.