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General NPI Number Information
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NPI Number | 1164141065
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Entity Type | Organization
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Legal Business Name | GRAND CANYON MEDICAL CLINIC PLLC
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Dates
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Enumeration Date | 08/24/2022
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Last Update Date | 02/20/2024
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Provider Practice Location Address
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Address Line | 1841 W 25TH ST STE B
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City | YUMA
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State | AZ
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Zip | 85364-6931
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Country | US
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Telephone | 928-503-7246
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Fax |
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Provider Business Mailing Address
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Address Line | 1329 W 20TH ST
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City | YUMA
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State | AZ
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Zip | 85364-5321
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Country | US
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Telephone | 928-503-7246
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ALEX D GALVEZ
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Credential | FNP
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Telephone | 928-350-8507
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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