Provider Demographics
NPI:1316711021
Name:THE CORVALLIS CLINIC P C
Entity type:Organization
Organization Name:THE CORVALLIS CLINIC P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAGNOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-754-1374
Mailing Address - Street 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:541-754-1374
Mailing Address - Fax:
Practice Address - Street 1:1705 WAVERLY DR SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6952
Practice Address - Country:US
Practice Address - Phone:541-967-8221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CORVALLIS CLINIC P C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-13
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies