Provider Demographics
NPI:1336697432
Name:GRAND PRIMARY CARE CLINICS
Entity Type:Organization
Organization Name:GRAND PRIMARY CARE CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:J
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-418-2929
Mailing Address - Street 1:5401 N PORTLAND AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2121
Mailing Address - Country:US
Mailing Address - Phone:405-605-0108
Mailing Address - Fax:405-463-0120
Practice Address - Street 1:5401 N PORTLAND AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2121
Practice Address - Country:US
Practice Address - Phone:405-605-0108
Practice Address - Fax:405-463-0120
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIMBACO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-17
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid