MEDICARE: GRANDEUR MEDICAL OFFICE INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1154341527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANDEUR MEDICAL OFFICE INC.

Provider Business Mailing Address
First Line	:	6517 TAFT ST
Second Line	:	SUITE 204
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-4048
Country	:	US
Telephone Number	:	786-554-8616
Fax Number	:

Provider Business Practice Location Address
First Line	:	6517 TAFT ST
Second Line	:	SUITE 204
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-4048
Country	:	US
Telephone Number	:	786-554-8616
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	YVONNE PHILLIPS
Credential	:
Telephone Number	:	786-554-8616

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	08/22/2020

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