Provider Demographics
NPI:1801891668
Name:CASCADE SPINE CENTER, LLC
Entity type:Organization
Organization Name:CASCADE SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFIICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:6464 SW BORLAND RD
Mailing Address - Street 2:BLDG A STE A-3
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8876
Mailing Address - Country:US
Mailing Address - Phone:971-404-3366
Mailing Address - Fax:971-404-3377
Practice Address - Street 1:6464 SW BORLAND RD
Practice Address - Street 2:BLDG A STE A-3
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8876
Practice Address - Country:US
Practice Address - Phone:971-404-3366
Practice Address - Fax:971-404-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR071546261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR299326Medicaid
ORP00082443OtherRAILROAD MEDICARE
ORP00082443OtherRAILROAD MEDICARE
OR299326Medicaid