Provider Demographics
NPI:1659307973
Name:GRANTS PASS IMAGING AND DIAGNOTIC CENTER, LLC
Entity Type:Organization
Organization Name:GRANTS PASS IMAGING AND DIAGNOTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CLAGUE
Authorized Official - Last Name:OEHLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-472-5154
Mailing Address - Street 1:1619 NW HAWTHORNE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-6009
Mailing Address - Country:US
Mailing Address - Phone:541-472-5154
Mailing Address - Fax:541-472-5178
Practice Address - Street 1:1619 NW HAWTHORNE AVE STE 204
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-6009
Practice Address - Country:US
Practice Address - Phone:541-472-5154
Practice Address - Fax:541-472-5178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR170137Medicaid
OR110821Medicare ID - Type UnspecifiedPROVIDER NUMBER