Healthcare Provider Details

I. General information

NPI: 1043403918
Provider Name (Legal Business Name): GRUNER CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6180 MAIN ST SUITE B
ZACHARY LA
70791-4069
US

IV. Provider business mailing address

6180 MAIN ST SUITE B
ZACHARY LA
70791-4069
US

V. Phone/Fax

Practice location:
  • Phone: 225-658-5959
  • Fax: 225-658-9998
Mailing address:
  • Phone: 225-658-5959
  • Fax: 225-658-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number024988
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number023672
License Number StateLA

VIII. Authorized Official

Name: DR. RACHEL MIER GRUNER
Title or Position: OWNER
Credential: M.D.
Phone: 225-658-5959