Provider Demographics
NPI:1881777084
Name:GRANBY FAMILY CLINIC LLC
Entity type:Organization
Organization Name:GRANBY FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CS, FNP-C
Authorized Official - Phone:417-472-7200
Mailing Address - Street 1:PO BOX 620
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:MO
Mailing Address - Zip Code:64844-0620
Mailing Address - Country:US
Mailing Address - Phone:417-472-7200
Mailing Address - Fax:417-472-7201
Practice Address - Street 1:201 GRANBY MINERS RD
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:MO
Practice Address - Zip Code:64844-8232
Practice Address - Country:US
Practice Address - Phone:417-472-7200
Practice Address - Fax:417-472-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO089423332B00000X, 332BC3200X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care