Provider Demographics
NPI:1154555076
Name:VILLAGE HEALTHCARE OF LA GRANDE, INC.
Entity type:Organization
Organization Name:VILLAGE HEALTHCARE OF LA GRANDE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER PROVIDER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-552-0386
Mailing Address - Street 1:656 NW MIRADOR PL
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4698
Mailing Address - Country:US
Mailing Address - Phone:541-552-0386
Mailing Address - Fax:503-200-2258
Practice Address - Street 1:656 NW MIRADOR PL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4698
Practice Address - Country:US
Practice Address - Phone:541-624-2040
Practice Address - Fax:503-200-2258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450130NP261Q00000X
305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131713Medicaid
OR269505Medicaid