Healthcare Provider Details

I. General information

NPI: 1679939318
Provider Name (Legal Business Name): CRATER LAKE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 BENNETT AVE
MEDFORD OR
97504-6715
US

IV. Provider business mailing address

825 BENNETT AVE
MEDFORD OR
97504-6715
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-5228
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH SAVINO
Title or Position: MEMBER
Credential: M.D.
Phone: 541-779-5228