Basic Information
| Provider Information | |||||||||
| NPI: | 1104164359 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONFEDERATED TRIBES OF GRAND RONDE COMMUNITY OF OREGON DBA GR HEALTH & | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 338 | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973470338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9605 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792236 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2013 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5038794638 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONFEDERATED TRIBES OF GRAND RONDE COMMUNITY OF OREGON | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 201070009CNS | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.