Provider Demographics
NPI:1639195340
Name:J1 MEDICAL CLINIC
Entity Type:Organization
Organization Name:J1 MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUTOC
Authorized Official - Middle Name:C
Authorized Official - Last Name:TRANDINH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-471-0120
Mailing Address - Street 1:PO BOX 2196
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97528-0276
Mailing Address - Country:US
Mailing Address - Phone:541-471-0120
Mailing Address - Fax:541-471-0118
Practice Address - Street 1:124 NW MIDLAND AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1269
Practice Address - Country:US
Practice Address - Phone:541-471-0120
Practice Address - Fax:541-471-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24478261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227321Medicaid
ORR133213Medicare ID - Type Unspecified
OR227321Medicaid