Provider Demographics
NPI:1740055599
Name:GRAND WEST FAMILY PRACTICE AND WELLNESS LLC
Entity type:Organization
Organization Name:GRAND WEST FAMILY PRACTICE AND WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:TELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:623-824-5017
Mailing Address - Street 1:13000 N 103RD AVE STE 77
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3057
Mailing Address - Country:US
Mailing Address - Phone:480-284-5650
Mailing Address - Fax:480-284-6431
Practice Address - Street 1:13000 N 103RD AVE STE 77
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3057
Practice Address - Country:US
Practice Address - Phone:480-284-5650
Practice Address - Fax:480-284-6431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-21
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty