Healthcare Provider Details

I. General information

NPI: 1174553929
Provider Name (Legal Business Name): GRANDE RONDE HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 4TH ST
LA GRANDE OR
97850-1906
US

IV. Provider business mailing address

PO BOX 460
LA GRANDE OR
97850-0460
US

V. Phone/Fax

Practice location:
  • Phone: 541-963-3138
  • Fax: 541-963-5918
Mailing address:
  • Phone: 541-963-3138
  • Fax: 541-963-5918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY P DAVIS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 541-963-8421