1104124403 NPI number — MRS. DELL RENEE GRINER NP-C

Table of content: MRS. DELL RENEE GRINER NP-C (NPI 1104124403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104124403 NPI number — MRS. DELL RENEE GRINER NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRINER
Provider First Name:
DELL
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRITT
Provider Other First Name:
DELL
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1104124403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8668
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31908-8668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-243-4594
Provider Business Mailing Address Fax Number:
706-243-4596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 MANCHESTER EXPY
Provider Second Line Business Practice Location Address:
STE C001
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31904-6802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-243-4594
Provider Business Practice Location Address Fax Number:
706-243-4596
Provider Enumeration Date:
03/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN112041 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003113112 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20250I0976 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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