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General NPI Number Information
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NPI Number | 1265519623
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Entity Type | Organization
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Legal Business Name | GRAND MEDICAL CLINIC
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 11/20/2009
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Provider Practice Location Address
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Address Line | 1416 S HAYDEN ST
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City | AMARILLO
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State | TX
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Zip | 79102-1635
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Country | US
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Telephone | 806-374-1919
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Fax | 806-379-9213
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Provider Business Mailing Address
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Address Line | 1416 S HAYDEN ST
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City | AMARILLO
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State | TX
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Zip | 79102-1635
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Country | US
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Telephone | 806-374-1919
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Fax | 806-379-9213
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER OWNER
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Name | MS. SUSAN A BALTZ
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Credential | FAMILY NURSE PRACTIT
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Telephone | 806-374-1919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | K2883
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License Number State | TX
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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 | 251159
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License Number State | TX
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