Provider Demographics
NPI:1487620472
Name:RIVER ROAD SURGERY CENTER LLC
Entity type:Organization
Organization Name:RIVER ROAD SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROCHELL
Authorized Official - Middle Name:ANN BLAIR
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-485-2584
Mailing Address - Street 1:3099 RIVER RD S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9754
Mailing Address - Country:US
Mailing Address - Phone:503-361-3094
Mailing Address - Fax:503-485-2168
Practice Address - Street 1:3099 RIVER RD S
Practice Address - Street 2:SUITE 100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-9754
Practice Address - Country:US
Practice Address - Phone:503-361-3094
Practice Address - Fax:503-485-2168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07 1529261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR239968Medicaid
ORR107980Medicare PIN