Basic Information
| Provider Information | |||||||||
| NPI: | 1194194902 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRANDE RONDE HOSPITAL, INC | ||||||||
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| OtherOrganizationName: | GRANDE RONDE HOSPITAL SLEEP CLINIC -CALDWELL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3290 | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978507290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419638421 | ||||||||
| FaxNumber: | 5419631845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836054802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083674817 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2015 | ||||||||
| LastUpdateDate: | 09/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | MATTES | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5419631842 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS1201X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine |
No ID Information.