Provider Demographics
NPI:1104164359
Name:CONFEDERATED TRIBES OF GRAND RONDE COMMUNITY OF OREGON DBA GR HEALTH &
Entity type:Organization
Organization Name:CONFEDERATED TRIBES OF GRAND RONDE COMMUNITY OF OREGON DBA GR HEALTH &
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-879-4638
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:GRAND RONDE
Mailing Address - State:OR
Mailing Address - Zip Code:97347-0338
Mailing Address - Country:US
Mailing Address - Phone:503-879-2236
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RONDE RD
Practice Address - Street 2:
Practice Address - City:GRAND RONDE
Practice Address - State:OR
Practice Address - Zip Code:97347-9712
Practice Address - Country:US
Practice Address - Phone:503-879-2236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONFEDERATED TRIBES OF GRAND RONDE COMMUNITY OF OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201070009CNS261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health