=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275158453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANDE RONDE HOSPITAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2020
-----------------------------------------------------
Last Update Date | 06/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10303 S WALTON RD
-----------------------------------------------------
City | LA GRANDE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-962-7845
-----------------------------------------------------
Fax | 541-975-5225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3290
-----------------------------------------------------
City | LA GRANDE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97850-7290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-962-7845
-----------------------------------------------------
Fax | 541-975-5225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | ANGELA J HIBBERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 541-963-1967
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------