Provider Demographics
NPI:1881694792
Name:WILLAMETTE SPINE CENTER AMBULATORY SURGERY LLC
Entity type:Organization
Organization Name:WILLAMETTE SPINE CENTER AMBULATORY SURGERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:D
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:NEMEC
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:503-485-2290
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-1267
Mailing Address - Country:US
Mailing Address - Phone:503-485-2290
Mailing Address - Fax:
Practice Address - Street 1:2480 LIBERTY ST NE
Practice Address - Street 2:SUITE 120
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97303-6780
Practice Address - Country:US
Practice Address - Phone:503-485-2290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227889Medicaid
ORR112286Medicare ID - Type Unspecified