NPIMap

Organization Active NPI

Evergreen Eye Center, PLLC

Doing business as Evergreen Eye Surgery Center

  • Ambulatory Surgical Clinic/Center
  • Federal Way, WA
National Provider Identifier
1821167479
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
Doing business as
Evergreen Eye Surgery Center
Practice address
34719 6TH Ave S
Federal Way, WA 98003-8714
Phone
(206) 212-2100
Fax
(206) 212-2174
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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Ambulatory Surgical Clinic/Center 261QA1903X 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 6

IdentifierTypeStateIssuer
490003159OtherWARAILROAD MEDICARE ASC NUM
7081250MedicaidWA
EV5682OtherWAREGENCE ASC NUMBER
P06705OtherWAPCMB ASC NUMBER
111881OtherWAL&I ASC NUMBER
NBNOtherWAWA0527

Other names 1

  • Evergreen Eye Surgery Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040304000105 WA Part B Supplier - Ambulatory Surgical Center 3173410057 Receives reassigned benefits from 2 practitioners
Practice locations: Federal Way, 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 50C0001131
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
Evergreen Eye Center PLLC11 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

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

Practitioners & affiliated clinicians

Practitioners 52

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 52

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": "1821167479",
    "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": "206-212-2171"
        },
        {
            "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": "206-212-2174"
        }
    ],
    "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": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE ASC NUM",
            "identifier": "490003159",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7081250",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE ASC NUMBER",
            "identifier": "EV5682",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PCMB ASC NUMBER",
            "identifier": "P06705",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "L&I ASC NUMBER",
            "identifier": "111881",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WA0527",
            "identifier": "NBN",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Eye Surgery Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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 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.