Provider Demographics
NPI:1730121401
Name:SALEM ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:SALEM ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ZOE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WENDOLOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:503-561-8170
Mailing Address - Street 1:875 OAK ST SE
Mailing Address - Street 2:SUITE 3095
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3975
Mailing Address - Country:US
Mailing Address - Phone:503-561-8170
Mailing Address - Fax:503-561-8167
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:SUITE 3095
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-561-8170
Practice Address - Fax:503-561-8167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR071573261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005765Medicaid
ORP00280629OtherRAILROAD MEDICARE
OR102447500OtherREGENCE BCBS
ORP356301OtherPACIFIC SOURCE
OR339145OtherPROVIDENCE
OR005765Medicaid