Healthcare Provider Details

I. General information

NPI: 1346558483
Provider Name (Legal Business Name): GRANT CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 S COEUR D ALENE LN SUITE D
PAYSON AZ
85541-5662
US

IV. Provider business mailing address

708 S COEUR DALENE LANE SUITE D
PAYSON AZ
85541-5662
US

V. Phone/Fax

Practice location:
  • Phone: 928-468-1337
  • Fax: 928-468-1339
Mailing address:
  • Phone: 928-468-1337
  • Fax: 928-468-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number1609
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number1609
License Number StateAZ

VIII. Authorized Official

Name: MARC GRANT
Title or Position: PRESIDENT
Credential: D.O.
Phone: 602-327-0184