Provider Demographics
NPI:1235466996
Name:THE GRANT CLINIC, LLC
Entity Type:Organization
Organization Name:THE GRANT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-327-0184
Mailing Address - Street 1:PO BOX 45379
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-5379
Mailing Address - Country:US
Mailing Address - Phone:602-327-0184
Mailing Address - Fax:602-358-8063
Practice Address - Street 1:14640 N TATUM BLVD STE 7
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4824
Practice Address - Country:US
Practice Address - Phone:602-327-0184
Practice Address - Fax:602-358-8063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1609207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZB46272Medicare UPIN
AZ102973Medicare PIN