Provider Demographics
NPI:1295329910
Name:GRANT WELLNESS CLINIC, LLC
Entity type:Organization
Organization Name:GRANT WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:256-728-7620
Mailing Address - Street 1:4630 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:AL
Mailing Address - Zip Code:35747-8308
Mailing Address - Country:US
Mailing Address - Phone:256-728-7620
Mailing Address - Fax:
Practice Address - Street 1:4630 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:AL
Practice Address - Zip Code:35747-8308
Practice Address - Country:US
Practice Address - Phone:256-728-7620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-23
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty