Provider Demographics
NPI:1053304394
Name:WINDING WATERS CLINIC PC
Entity Type:Organization
Organization Name:WINDING WATERS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRANDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-426-4502
Mailing Address - Street 1:603 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-5124
Mailing Address - Country:US
Mailing Address - Phone:541-426-4502
Mailing Address - Fax:541-426-6403
Practice Address - Street 1:603 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-5124
Practice Address - Country:US
Practice Address - Phone:541-426-4502
Practice Address - Fax:541-426-6403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
OR383864261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OROR01145OtherMEDICARE EMC SUBMITTER
OR223198Medicaid
ORCG2920OtherRAILROAD MEDICARE
ORCG2920OtherRAILROAD MEDICARE
OROR01145OtherMEDICARE EMC SUBMITTER
OROR01145OtherMEDICARE EMC SUBMITTER