Provider Demographics
NPI:1346558483
Name:GRANT CLINIC LLC
Entity Type:Organization
Organization Name: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 1:708 S COEUR DALENE LANE
Mailing Address - Street 2:SUITE D
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5662
Mailing Address - Country:US
Mailing Address - Phone:928-468-1337
Mailing Address - Fax:928-468-1339
Practice Address - Street 1:708 S COEUR D ALENE LN
Practice Address - Street 2:SUITE D
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5662
Practice Address - Country:US
Practice Address - Phone:928-468-1337
Practice Address - Fax:928-468-1339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1609207LA0401X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ140941Medicare PIN