Healthcare Provider Details

I. General information

NPI: 1417405333
Provider Name (Legal Business Name): EVERGREEN TREATMENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 SW 43RD ST SUITE 140
RENTON WA
98057-4803
US

IV. Provider business mailing address

1700 AIRPORT WAY S
SEATTLE WA
98134-1618
US

V. Phone/Fax

Practice location:
  • Phone: 425-264-0750
  • Fax: 425-264-0799
Mailing address:
  • Phone: 206-223-3644
  • Fax: 206-223-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number17 0163 00
License Number StateWA

VIII. Authorized Official

Name: MARGARET CARNEY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 206-223-3644