Healthcare Provider Details

I. General information

NPI: 1881694792
Provider Name (Legal Business Name): WILLAMETTE SPINE CENTER AMBULATORY SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 LIBERTY ST NE SUITE 120
SALEM OR
97303-6780
US

IV. Provider business mailing address

PO BOX 1267
PORTLAND OR
97207-1267
US

V. Phone/Fax

Practice location:
  • Phone: 503-485-2290
  • Fax:
Mailing address:
  • Phone: 503-485-2290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. D KAY NEMEC
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 503-485-2290