Healthcare Provider Details

I. General information

NPI: 1174666358
Provider Name (Legal Business Name): CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

IV. Provider business mailing address

PO BOX 338
GRAND RONDE OR
97347-0338
US

V. Phone/Fax

Practice location:
  • Phone: 503-879-2236
  • Fax: 503-879-5089
Mailing address:
  • Phone: 503-879-2236
  • Fax: 503-879-5089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number126883
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number445142
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number38D0862855
License Number StateOR
# 7
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1559
License Number StateOR
# 12
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 14
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KELLY D ROWE
Title or Position: EXECUTIVE DIRECTOR HEALTH SERVICES
Credential:
Phone: 503-879-2075