Healthcare Provider Details

I. General information

NPI: 1093998866
Provider Name (Legal Business Name): GRANDE RONDE RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 I AVE
LA GRANDE OR
97850-2043
US

IV. Provider business mailing address

1101 I AVE
LA GRANDE OR
97850-2043
US

V. Phone/Fax

Practice location:
  • Phone: 541-962-0162
  • Fax:
Mailing address:
  • Phone: 541-962-0162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMD18191
License Number StateOR

VIII. Authorized Official

Name: MEGGEN M BROGOITTI
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-962-0162