=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386113090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGERY CENTER OF MT. SCOTT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2018
-----------------------------------------------------
Last Update Date | 11/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9300 SE 91ST AVE STE 101
-----------------------------------------------------
City | HAPPY VALLEY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97086-3762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-808-1559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9300 SE 91ST AVE STE 101
-----------------------------------------------------
City | HAPPY VALLEY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97086-3762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-808-1559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE PARALEGAL
-----------------------------------------------------
Name | MS. KINESHIA COLLINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-263-7863
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------