Healthcare Provider Details

I. General information

NPI: 1568717304
Provider Name (Legal Business Name): THE GRANDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 DESOTO AVE
BROOKSVILLE FL
34601-2813
US

IV. Provider business mailing address

725 DESOTO AVE
BROOKSVILLE FL
34601-2813
US

V. Phone/Fax

Practice location:
  • Phone: 352-544-0944
  • Fax: 352-544-0922
Mailing address:
  • Phone: 352-544-0944
  • Fax: 352-544-0922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberAL11732
License Number StateFL

VIII. Authorized Official

Name: DAVID JONES
Title or Position: PART OWNER
Credential:
Phone: 727-683-1200