Provider Demographics
NPI:1851520514
Name:CAPITOL SURGERY CENTER LLC
Entity Type:Organization
Organization Name:CAPITOL SURGERY CENTER LLC
Other - Org Name:WAVERLY LAKE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:D
Authorized Official - Last Name:KOLB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-918-4210
Mailing Address - Street 1:633 WAVERLY DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-5078
Mailing Address - Country:US
Mailing Address - Phone:541-918-4210
Mailing Address - Fax:541-918-4215
Practice Address - Street 1:633 WAVERLY DR SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-5078
Practice Address - Country:US
Practice Address - Phone:541-918-4210
Practice Address - Fax:541-918-4215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical