Healthcare Provider Details

I. General information

NPI: 1568527539
Provider Name (Legal Business Name): EVERGREEN CHILDREN'S CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 S MERIDIAN SUITE A
PUYALLUP WA
98371-7531
US

IV. Provider business mailing address

1910 S MERIDIAN SUITE A
PUYALLUP WA
98371-7531
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-2303
  • Fax: 253-848-8956
Mailing address:
  • Phone: 253-848-2303
  • Fax: 253-848-8956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUSANNE I ROACH
Title or Position: OFFICE MANAGER
Credential:
Phone: 253-848-2303