Provider Demographics
NPI:1043403918
Name:GRUNER CLINIC, LLC
Entity type:Organization
Organization Name:GRUNER CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:MIER
Authorized Official - Last Name:GRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-658-5959
Mailing Address - Street 1:6180 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4069
Mailing Address - Country:US
Mailing Address - Phone:225-658-5959
Mailing Address - Fax:225-658-9998
Practice Address - Street 1:6180 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4069
Practice Address - Country:US
Practice Address - Phone:225-658-5959
Practice Address - Fax:225-658-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024988207R00000X
LA023672208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1444821Medicaid
LA1444821Medicaid