Basic Information
| Provider Information | |||||||||
| NPI: | 1174666358 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAND RONDE HEALTH AND WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 338 | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973470338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792236 | ||||||||
| FaxNumber: | 5038795089 | ||||||||
| Practice Location | |||||||||
| Address1: | 9605 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792236 | ||||||||
| FaxNumber: | 5038795089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROWE | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR HEALTH SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5038792075 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 133V00000X | 088 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X | 126883 | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QR0200X | 445142 | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 291U00000X | 38D0862855 | OR | N | Laboratories | Clinical Medical Laboratory | 333600000X | 1559 | OR | N | Suppliers | Pharmacy | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 126883 | 05 | OR | MEDICAID |