Basic Information
| Provider Information | |||||||||
| NPI: | 1780068080 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRANDE RONDE HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | GRANDE RONDE HOSPITAL UNION 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: | 142 E DEARBORN | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419631555 | ||||||||
| FaxNumber: | 5419631845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2015 | ||||||||
| LastUpdateDate: | 11/21/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATTES | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5419631464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.