Healthcare Provider Details

I. General information

NPI: 1235466996
Provider Name (Legal Business Name): THE GRANT CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14640 N TATUM BLVD STE 7
PHOENIX AZ
85032-4824
US

IV. Provider business mailing address

PO BOX 45379
PHOENIX AZ
85064-5379
US

V. Phone/Fax

Practice location:
  • Phone: 602-327-0184
  • Fax: 602-358-8063
Mailing address:
  • Phone: 602-327-0184
  • Fax: 602-358-8063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARC GRANT
Title or Position: PRESIDENT
Credential: DO
Phone: 602-327-0184