Basic Information
| Provider Information | |||||||||
| NPI: | 1205056322 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KING COUNTY PUBLIC HOSPITAL DISTRICT #2 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EVERGREEN HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12040 NE 128TH ST | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980343013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258991000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12040 NE 128TH ST | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980343013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258991000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YAMADA | ||||||||
| AuthorizedOfficialFirstName: | CHRISSY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4258992600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | WA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 9056714 | 05 | WA | MEDICAID |