Provider Demographics
NPI:1972192896
Name:BOARDMAN SURGICAL LLC
Entity Type:Organization
Organization Name:BOARDMAN SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOARDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CSFA
Authorized Official - Phone:503-307-0159
Mailing Address - Street 1:15074 SE BEVINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-3357
Mailing Address - Country:US
Mailing Address - Phone:503-307-0159
Mailing Address - Fax:
Practice Address - Street 1:1500 DIVISION ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1527
Practice Address - Country:US
Practice Address - Phone:503-650-6762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty