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
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 111N00000X, 1223G0001X, 152W00000X, 208D00000X, 261QC1500X, 332800000X, 363LF0000X, 363LP2300X, 332800000X
OR126883261QF0400X
OR445142261QR0200X
OR38D0862855291U00000X
OR1559333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) PharmacyGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No333600000XSuppliersPharmacyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500786332Medicaid
OR126883Medicaid