Basic Information
| Provider Information | |||||||||
| NPI: | 1366679227 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE GRANT CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 39179 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850699179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 N 18TH ST | ||||||||
| Address2: | 403 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850064102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022544228 | ||||||||
| FaxNumber: | 6022546380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2009 | ||||||||
| LastUpdateDate: | 06/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | DIGGES | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6023950718 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.