=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982420329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND SUMMIT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2024
-----------------------------------------------------
Last Update Date | 05/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13207 CENTRAL AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87123-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-595-1607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9909 ROBIN AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-4061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-274-3556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | BAKHTAR EHSAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 831-325-3541
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2800X
-----------------------------------------------------
Taxonomy Name | Methadone Clinic
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------