Provider Demographics
NPI:1760530497
Name:VIVIAN NELL HANNON
Entity Type:Organization
Organization Name:VIVIAN NELL HANNON
Other - Org Name:GRANT FAMILY PRACTICE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:H
Authorized Official - Last Name:GEDLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-582-6377
Mailing Address - Street 1:1241 BLOUNT AVE NW
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976
Mailing Address - Country:US
Mailing Address - Phone:256-582-6377
Mailing Address - Fax:256-582-6376
Practice Address - Street 1:5447 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:AL
Practice Address - Zip Code:35747-6211
Practice Address - Country:US
Practice Address - Phone:256-728-2272
Practice Address - Fax:256-728-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL541003911Medicaid
AL541003911Medicaid