Healthcare Provider Details

I. General information

NPI: 1861434615
Provider Name (Legal Business Name): GRANDE RONDE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 SUNSET DR
LA GRANDE OR
97850-1248
US

IV. Provider business mailing address

612 SUNSET DR
LA GRANDE OR
97850-1248
US

V. Phone/Fax

Practice location:
  • Phone: 541-963-9123
  • Fax: 541-962-0695
Mailing address:
  • Phone: 541-963-9123
  • Fax: 541-962-0695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number394792
License Number StateOR

VIII. Authorized Official

Name: MR. JAMES MATTES
Title or Position: PRESIDENT
Credential:
Phone: 541-963-1469