NPIMap

Organization Active NPI

Evergreen Eye Center, PLLC

  • Ophthalmology Physician
  • Federal Way, WA
National Provider Identifier
1700959293
Registry record updated Jan 4, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
Legal business name
EVERGREEN EYE CENTER, PLLC
Practice address
34719 6TH Ave S
Federal Way, WA 98003-8714
Phone
(206) 212-2100
Fax
(206) 212-2194
NPI assigned
Nov 15, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 4, 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
OptometristGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 152W00000X
Ophthalmology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207W00000X Primary

Addresses

Primary practice location

34719 6TH Ave S
Federal Way, WA 98003-8714

Mailing address

34719 6TH Ave S
Federal Way, WA 98003-8714
Phone (206) 212-2100

Other identifiers 8

IdentifierTypeStateIssuer
0870427OtherWAAETNA NUMBER
WA0527OtherWAEEC NBN NUMBER
891451OtherWACRIME VICTIMS EEC NUMBER
EV8144OtherWAEEC KCM GROUP NUMBER
59460OtherWAEEC L&I NUMBER
7080781MedicaidWA
2017242MedicaidWA
P04799OtherWAPCMB GROUP EEC NUMBER

Other names 2

  • Evergreen Eye Center Doing business as
  • Evergreen Eye Center of Federal Way Inc., P.S. Former legal business name

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
Practice locations: Seattle, WA; Tacoma, WA; Federal Way, WA; Kirkland, WA; Auburn, WA; Edmonds, WA; Burien, WA

Other NPIs with the same Medicare PAC ID 4

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

Other NPIs on the same Medicare enrollment 6

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

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

700 M St NE
Auburn, WA 98002
Phone (206) 212-2100

33915 1st Way S
Ste 120A
Federal Way, WA 98003
Phone (206) 260-2504

Practitioners & affiliated clinicians

Practitioners 41

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 41

NPI Registry JSON

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

{
    "created_epoch": "1163548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1704326400000",
    "number": "1700959293",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "34719 6TH AVE S",
            "city": "FEDERAL WAY",
            "state": "WA",
            "postal_code": "980038714",
            "telephone_number": "206-212-2100",
            "fax_number": "253-661-7383"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "34719 6TH AVE S",
            "city": "FEDERAL WAY",
            "state": "WA",
            "postal_code": "980038714",
            "telephone_number": "206-212-2100",
            "fax_number": "206-212-2194"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN EYE CENTER, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-15",
        "last_updated": "2024-01-04",
        "certification_date": "2024-01-04",
        "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": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Ophthalmology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA NUMBER",
            "identifier": "0870427",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EEC NBN NUMBER",
            "identifier": "WA0527",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CRIME VICTIMS EEC NUMBER",
            "identifier": "891451",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EEC KCM GROUP NUMBER",
            "identifier": "EV8144",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EEC L&I NUMBER",
            "identifier": "59460",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7080781",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2017242",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PCMB GROUP EEC NUMBER",
            "identifier": "P04799",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Eye Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Evergreen Eye Center of Federal Way Inc., P.S.",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "Evergreen Eye Center of Federal Way Inc., P.S.",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Federal Way, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 4, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.