Provider Demographics
NPI:1609980655
Name:GRANDE RONDE HOSPITAL, INC
Entity Type:Organization
Organization Name:GRANDE RONDE HOSPITAL, INC
Other - Org Name:GRANDE RONDE HOSPITAL
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:541-963-8421
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:97850-1362
Practice Address - Country:US
Practice Address - Phone:541-963-8421
Practice Address - Fax:541-963-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR394792275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR38Z321Medicare Oscar/Certification