Provider Demographics
NPI:1467446195
Name:GRANDE RONDE HOSPITAL, INC.
Entity Type:Organization
Organization Name:GRANDE RONDE HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:P
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-963-8421
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:541-963-8421
Mailing Address - Fax:541-963-1845
Practice Address - Street 1:900 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3290
Practice Address - Country:US
Practice Address - Phone:541-963-1472
Practice Address - Fax:541-963-1862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QM0801X, 261QM1300X, 261QP2000X, 261QP2300X, 261QS1200X, 261QU0200X, 282NC0060X
OR140728282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067801Medicaid
OR38Z321Medicare Oscar/Certification
OR381321Medicare Oscar/Certification
OR067801Medicaid
OR381321Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
OR0000ZGBDROtherMEDICARE PART B
ORP010001OtherPACIFIC SOURCE
ORC45104OtherRR-MEDICARE