Healthcare Provider Details

I. General information

NPI: 1801891668
Provider Name (Legal Business Name): CASCADE SPINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6464 SW BORLAND RD BLDG A STE A-3
TUALATIN OR
97062-8876
US

IV. Provider business mailing address

6464 SW BORLAND RD BLDG A STE A-3
TUALATIN OR
97062-8876
US

V. Phone/Fax

Practice location:
  • Phone: 971-404-3366
  • Fax: 971-404-3377
Mailing address:
  • Phone: 971-404-3366
  • Fax: 971-404-3377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number071546
License Number StateOR

VIII. Authorized Official

Name: ERIC BOON
Title or Position: OFFIICER/AUTHORIZED OFFICIAL
Credential:
Phone: 480-567-0269