Provider Demographics
NPI: | 1174666358 |
---|---|
Name: | CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON |
Entity Type: | Organization |
Organization Name: | CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON |
Other - Org Name: | GRAND RONDE HEALTH AND WELLNESS CENTER |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR HEALTH SERVICES |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KELLY |
Authorized Official - Middle Name: | D |
Authorized Official - Last Name: | ROWE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 503-879-2075 |
Mailing Address - Street 1: | PO BOX 338 |
Mailing Address - Street 2: | |
Mailing Address - City: | GRAND RONDE |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97347-0338 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-879-2236 |
Mailing Address - Fax: | 503-879-5089 |
Practice Address - Street 1: | 9605 GRAND RONDE RD |
Practice Address - Street 2: | |
Practice Address - City: | GRAND RONDE |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97347-9712 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-879-2236 |
Practice Address - Fax: | 503-879-5089 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-02-15 |
Last Update Date: | 2024-02-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101Y00000X, 101YA0400X, 111N00000X, 1223G0001X, 152W00000X, 208D00000X, 261QC1500X, 332800000X, 363LF0000X, 363LP2300X, 332800000X | ||
OR | 126883 | 261QF0400X |
OR | 445142 | 261QR0200X |
OR | 38D0862855 | 291U00000X |
OR | 1559 | 333600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 332800000X | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy | Group - Multi-Specialty | |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty | |
No | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |
No | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
No | 261QC1500X | Ambulatory Health Care Facilities | Clinic/Center | Community Health | Group - Multi-Specialty |
No | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | Group - Multi-Specialty |
No | 261QR0200X | Ambulatory Health Care Facilities | Clinic/Center | Radiology | Group - Multi-Specialty |
No | 291U00000X | Laboratories | Clinical Medical Laboratory | Group - Multi-Specialty | |
No | 333600000X | Suppliers | Pharmacy | Group - Multi-Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 500786332 | Medicaid | |
OR | 126883 | Medicaid |