Basic Information
| Provider Information | |||||||||
| NPI: | 1477932325 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANDE RONDE HOSPITAL, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRANDE RONDE HOSPITAL ELGIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3290 | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978507290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419631555 | ||||||||
| FaxNumber: | 5419631845 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414376321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2015 | ||||||||
| LastUpdateDate: | 08/25/2015 | ||||||||
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| AuthorizedOfficialLastName: | MATTES | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5419631454 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.