Provider Demographics
NPI:1689061491
Name:GRANDE RONDE HOSPITAL, INC
Entity Type:Organization
Organization Name:GRANDE RONDE HOSPITAL, INC
Other - Org Name:GRANDE RONDE HOSPITAL WOMEN'S & CHILDREN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-963-1454
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:541-963-1555
Mailing Address - Fax:541-963-1845
Practice Address - Street 1:610 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1269
Practice Address - Country:US
Practice Address - Phone:541-963-1555
Practice Address - Fax:541-963-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR140728261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR388525Medicare Oscar/Certification