Provider Demographics
NPI:1629550892
Name:GRAND PRAIRIE SERVICES
Entity Type:Organization
Organization Name:GRAND PRAIRIE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHARRONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-444-1012
Mailing Address - Street 1:17746 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3936
Mailing Address - Country:US
Mailing Address - Phone:708-444-1012
Mailing Address - Fax:
Practice Address - Street 1:450 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-2463
Practice Address - Country:US
Practice Address - Phone:708-985-3040
Practice Address - Fax:708-474-8144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-04
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty