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General NPI Number Information
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NPI Number | 1154555076
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Entity Type | Organization
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Legal Business Name | VILLAGE HEALTHCARE OF LA GRANDE, INC.
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Dates
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Enumeration Date | 05/06/2009
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Last Update Date | 11/19/2019
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Provider Practice Location Address
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Address Line | 656 NW MIRADOR PL
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City | CORVALLIS
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State | OR
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Zip | 97330-4698
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Country | US
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Telephone | 541-624-2040
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Fax | 503-200-2258
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Provider Business Mailing Address
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Address Line | 656 NW MIRADOR PL
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City | CORVALLIS
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State | OR
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Zip | 97330-4698
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Country | US
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Telephone | 541-552-0386
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Fax | 503-200-2258
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Authorized Official
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Title or Position | MANAGER PROVIDER PRESIDENT
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Name | RENEE EDWARDS
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Credential | FNP
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Telephone | 541-552-0386
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 200450130NP
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License Number State | OR
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