Provider Demographics
NPI:1023271459
Name:RIVERBEND AMBULATORY SURGERY CENTER LLC
Entity type:Organization
Organization Name:RIVERBEND AMBULATORY SURGERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF BOARD OF MANAGERS
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOKKINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-320-6577
Mailing Address - Street 1:3355 RIVERBEND DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-8800
Mailing Address - Country:US
Mailing Address - Phone:541-852-4824
Mailing Address - Fax:541-242-5115
Practice Address - Street 1:3355 RIVERBEND DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-852-4824
Practice Address - Fax:541-242-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORIN PROCESS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1601OtherSTATE LICENSE