Provider Demographics
NPI:1386956704
Name:EVERGREEN FOOT & ANKLE SPECIALISTS PLLC
Entity type:Organization
Organization Name:EVERGREEN FOOT & ANKLE SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-694-3668
Mailing Address - Street 1:2415 SE 165TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4324
Mailing Address - Country:US
Mailing Address - Phone:360-694-3668
Mailing Address - Fax:360-882-3566
Practice Address - Street 1:2415 SE 165TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4324
Practice Address - Country:US
Practice Address - Phone:360-694-3668
Practice Address - Fax:360-882-3566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000682213ES0103X
WAPO000000682332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty