Provider Demographics
NPI:1073553715
Name:GRAND RIVER PSYCHIATRY PLLC
Entity Type:Organization
Organization Name:GRAND RIVER PSYCHIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:970-254-8600
Mailing Address - Street 1:743 HORIZON CT
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8701
Mailing Address - Country:US
Mailing Address - Phone:970-254-8600
Mailing Address - Fax:970-254-8603
Practice Address - Street 1:743 HORIZON CT
Practice Address - Street 2:STE 106
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8701
Practice Address - Country:US
Practice Address - Phone:970-254-8600
Practice Address - Fax:970-254-8603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC805333Medicare PIN