Healthcare Provider Details

I. General information

NPI: 1245120401
Provider Name (Legal Business Name): GRD LEASING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 S DOUGLAS BLVD
MIDWEST CITY OK
73130-5236
US

IV. Provider business mailing address

PO BOX 403
ELK CITY OK
73648-0403
US

V. Phone/Fax

Practice location:
  • Phone: 405-733-8000
  • Fax: 405-338-7455
Mailing address:
  • Phone: 405-265-6099
  • Fax: 405-338-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GRANT DETTEN
Title or Position: OWNER
Credential: DO
Phone: 580-716-7658