NPIMap

Organization Active NPI

Evergreen Eye Center, PLLC

Doing business as Evergreen Eye Center

  • Ophthalmology Physician
  • Burien, WA
National Provider Identifier
1538238043
Registry record updated Jan 12, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
Legal business name
EVERGREEN EYE CENTER, PLLC
Doing business as
Evergreen Eye Center
Practice address
15153 5TH Ave SW
Burien, WA 98166-3072
Phone
(800) 340-3595
Fax
(855) 929-1515
NPI assigned
Nov 7, 2006
Last updated
Jan 12, 2024By the provider in NPPES
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 Angelica Campos
Title
Credentialing Manager
Phone
(206) 215-2004

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X
Ophthalmology Physician 207W00000X Primary

Addresses

Primary practice location

15153 5TH Ave SW
Burien, WA 98166-3072

Mailing address

15153 5TH Ave SW
Burien, WA 98166-3072
Phone (206) 212-2100

Other identifiers 8

IdentifierTypeStateIssuer
0870427OtherWAAETNA
EV8144OtherWAKCM
P04799OtherWAPCMB
2017242MedicaidWA
891451OtherWACRIME VICTIMS
59460OtherWAL&I
7080781MedicaidWA
WA0527OtherWANBN

Other names 1

  • Evergreen Eye Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040304001193 WA Part B Supplier - Clinic/Group Practice 3173410057 Receives reassigned benefits from 40 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Seattle, WA; Tacoma, WA; Federal Way, WA; Kirkland, WA; Auburn, WA; Edmonds, WA; Burien, WA

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
50D2078287Evergreen Eye Center15153 5TH Ave SW, Burien, WA 98166Certificate of waiverApr 4, 2028

National Provider Directory

National Provider Directory
Tax ID family
Evergreen Eye Center in11 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

14031 Ambaum Blvd SW
Ste 1
Burien, WA 98166

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

Practitioners & affiliated clinicians

Practitioners 33

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 33

NPI Registry JSON

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

{
    "created_epoch": "1162857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705017600000",
    "number": "1538238043",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15153 5TH AVE SW",
            "city": "BURIEN",
            "state": "WA",
            "postal_code": "981663072",
            "telephone_number": "206-212-2100",
            "fax_number": "206-212-2174"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "15153 5TH AVE SW",
            "city": "BURIEN",
            "state": "WA",
            "postal_code": "981663072",
            "telephone_number": "800-340-3595",
            "fax_number": "855-929-1515"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN EYE CENTER, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-07",
        "last_updated": "2024-01-12",
        "certification_date": "2024-01-12",
        "status": "A",
        "authorized_official_last_name": "CAMPOS",
        "authorized_official_first_name": "ROSA",
        "authorized_official_middle_name": "ANGELICA",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "206-215-2004"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "0870427",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "KCM",
            "identifier": "EV8144",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PCMB",
            "identifier": "P04799",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2017242",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CRIME VICTIMS",
            "identifier": "891451",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "L&I",
            "identifier": "59460",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7080781",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NBN",
            "identifier": "WA0527",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Eye Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Burien, 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.