Provider Demographics
NPI:1184376931
Name:GRANDS PREMIER HEALTH & LAB DIAGNOSTICS LLC
Entity type:Organization
Organization Name:GRANDS PREMIER HEALTH & LAB DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANTEL
Authorized Official - Middle Name:ANTOIN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:770-990-4699
Mailing Address - Street 1:3347 SURVEYOR CT
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8102
Mailing Address - Country:US
Mailing Address - Phone:770-990-4699
Mailing Address - Fax:
Practice Address - Street 1:3347 SURVEYOR CT
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-8102
Practice Address - Country:US
Practice Address - Phone:770-990-4699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty