=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386956704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN FOOT & ANKLE SPECIALISTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2010
-----------------------------------------------------
Last Update Date | 09/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2415 SE 165TH AVE STE 104
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-4324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-694-3668
-----------------------------------------------------
Fax | 360-882-3566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2415 SE 165TH AVE STE 104
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-4324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-694-3668
-----------------------------------------------------
Fax | 360-882-3566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. KURT W DAVIS
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 360-694-3668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | PO000000682
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO00000682
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------