Provider Demographics
NPI:1366679227
Name:THE GRANT CLINIC, LLC
Entity Type:Organization
Organization Name:THE GRANT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIGGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-395-0718
Mailing Address - Street 1:PO BOX 39179
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85069-9179
Mailing Address - Country:US
Mailing Address - Phone:602-395-0718
Mailing Address - Fax:602-277-8146
Practice Address - Street 1:525 N 18TH ST
Practice Address - Street 2:403
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-4102
Practice Address - Country:US
Practice Address - Phone:602-254-4228
Practice Address - Fax:602-254-6380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain