Provider Demographics
NPI:1528397148
Name:GRAND PRAIRIE SERVICES
Entity Type:Organization
Organization Name:GRAND PRAIRIE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:REGNIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-444-1012
Mailing Address - Street 1:31 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-3556
Mailing Address - Country:US
Mailing Address - Phone:708-444-1012
Mailing Address - Fax:
Practice Address - Street 1:31 W 155TH ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3556
Practice Address - Country:US
Practice Address - Phone:708-444-1012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL668580Medicare PIN