1306183801 NPI number — GRANDE RONDE PSYCHIATRIC SERVICES, PC

Table of content: (NPI 1306183801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306183801 NPI number — GRANDE RONDE PSYCHIATRIC SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANDE RONDE PSYCHIATRIC SERVICES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306183801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1994 S BAGLEY CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ANGELES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98362-7454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-477-3298
Provider Business Mailing Address Fax Number:
360-452-9584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
435 W BELL ST
Provider Second Line Business Practice Location Address:
STE. B-1
Provider Business Practice Location Address City Name:
SEQUIM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98382-2916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-477-3298
Provider Business Practice Location Address Fax Number:
360-452-9584
Provider Enumeration Date:
01/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
TRUDEL
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-477-3298

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  MD60053143 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0265930 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 113092 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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