Basic Information
| Provider Information | |||||||||
| NPI: | 1326513367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONFEDERATED TRIBES OF GRAND RONDE COMMUNITY OF OREGON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9615 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792060 | ||||||||
| FaxNumber: | 5038795089 | ||||||||
| Practice Location | |||||||||
| Address1: | 9615 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792060 | ||||||||
| FaxNumber: | 5038795089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2018 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | MORFIN | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | QUALITY ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 5038792060 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 126883 | 05 | OR | MEDICAID |