Provider Demographics
NPI:1164731030
Name:GRAPEVINE CLINIC LLC
Entity Type:Organization
Organization Name:GRAPEVINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-788-6060
Mailing Address - Street 1:PO BOX 8670
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-8670
Mailing Address - Country:US
Mailing Address - Phone:928-788-6060
Mailing Address - Fax:928-788-6062
Practice Address - Street 1:5300 S HIGHWAY 95
Practice Address - Street 2:SUITE H
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9251
Practice Address - Country:US
Practice Address - Phone:928-788-6060
Practice Address - Fax:928-788-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZL-16288258OtherARIZONA LLC REGISTRATION