Healthcare Provider Details

I. General information

NPI: 1881777084
Provider Name (Legal Business Name): GRANBY FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 GRANBY MINERS RD
GRANBY MO
64844-8232
US

IV. Provider business mailing address

PO BOX 620
GRANBY MO
64844-0620
US

V. Phone/Fax

Practice location:
  • Phone: 417-472-7200
  • Fax: 417-472-7201
Mailing address:
  • Phone: 417-472-7200
  • Fax: 417-472-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number089423
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number089423
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number089423
License Number StateMO

VIII. Authorized Official

Name: WILLIAM G DAVIS
Title or Position: OWNER/MANAGER
Credential: RN, CS, FNP-C
Phone: 417-472-7200