1295284339 NPI number — SHANNON GRANT LLC

Table of content: (NPI 1851461271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295284339 NPI number — SHANNON GRANT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHANNON GRANT LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HANDS IN THE SAND THERAPEUTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295284339
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5831 BURGOS AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87114-5497
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-980-5513
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 ATRISCO DR NW
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87120-1688
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-980-5513
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GRANT
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
RAE
Authorized Official Title or Position:
THERAPIST/OWNER
Authorized Official Telephone Number:
505-980-5513

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  0129011 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22988378 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1689878605 . This is a "NPI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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