Healthcare Provider Details

I. General information

NPI: 1750107199
Provider Name (Legal Business Name): GRAND SUMMIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13139 CENTRAL AVE NE
ALBUQUERQUE NM
87123-3031
US

IV. Provider business mailing address

9909 ROBIN AVE NE
ALBUQUERQUE NM
87112-4061
US

V. Phone/Fax

Practice location:
  • Phone: 505-595-1607
  • Fax:
Mailing address:
  • Phone: 831-325-3541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BAKHTAR EHSAN
Title or Position: CFO
Credential:
Phone: 831-325-3541