Healthcare Provider Details

I. General information

NPI: 1154555076
Provider Name (Legal Business Name): VILLAGE HEALTHCARE OF LA GRANDE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 NW MIRADOR PL
CORVALLIS OR
97330-4698
US

IV. Provider business mailing address

656 NW MIRADOR PL
CORVALLIS OR
97330-4698
US

V. Phone/Fax

Practice location:
  • Phone: 541-624-2040
  • Fax: 503-200-2258
Mailing address:
  • Phone: 541-552-0386
  • Fax: 503-200-2258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number200450130NP
License Number StateOR

VIII. Authorized Official

Name: RENEE EDWARDS
Title or Position: MANAGER PROVIDER PRESIDENT
Credential: FNP
Phone: 541-552-0386