Provider Demographics
NPI:1669504585
Name:GRANT CLINIC
Entity type:Organization
Organization Name:GRANT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OLYMPIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-728-4219
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:AL
Mailing Address - Zip Code:35747-0429
Mailing Address - Country:US
Mailing Address - Phone:256-728-4219
Mailing Address - Fax:256-728-7793
Practice Address - Street 1:91 2ND AVE
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:AL
Practice Address - Zip Code:35747
Practice Address - Country:US
Practice Address - Phone:256-728-4219
Practice Address - Fax:256-728-7793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3517207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529600280Medicaid