Provider Demographics
NPI:1093296519
Name:GRANDE RONDE HOSPITAL, INC.
Entity Type:Organization
Organization Name:GRANDE RONDE HOSPITAL, INC.
Other - Org Name:GRANDE RONDE HOSPITAL WALK-IN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HIBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-963-1967
Mailing Address - Street 1:PO BOX 3290
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-7290
Mailing Address - Country:US
Mailing Address - Phone:541-962-7845
Mailing Address - Fax:541-975-5225
Practice Address - Street 1:10303 S WALTON RD
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-962-7845
Practice Address - Fax:541-975-5225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR140728261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health