Healthcare Provider Details

I. General information

NPI: 1386956704
Provider Name (Legal Business Name): EVERGREEN FOOT & ANKLE SPECIALISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 SE 165TH AVE STE 104
VANCOUVER WA
98683-4324
US

IV. Provider business mailing address

2415 SE 165TH AVE STE 104
VANCOUVER WA
98683-4324
US

V. Phone/Fax

Practice location:
  • Phone: 360-694-3668
  • Fax: 360-882-3566
Mailing address:
  • Phone: 360-694-3668
  • Fax: 360-882-3566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO00000682
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberPO000000682
License Number StateWA

VIII. Authorized Official

Name: DR. KURT W DAVIS
Title or Position: MANAGER
Credential: DPM
Phone: 360-694-3668