Provider Demographics
NPI:1134814874
Name:GRAND CANYON LAB LLC
Entity type:Organization
Organization Name:GRAND CANYON LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THEO
Authorized Official - Middle Name:BLAISE
Authorized Official - Last Name:RUKUNDO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MBA
Authorized Official - Phone:857-247-8763
Mailing Address - Street 1:4141 N 32ND ST STE 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4775
Mailing Address - Country:US
Mailing Address - Phone:857-247-8763
Mailing Address - Fax:
Practice Address - Street 1:4141 N 32ND ST STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-4775
Practice Address - Country:US
Practice Address - Phone:857-247-8763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory