Provider Demographics
NPI:1023880861
Name:GRAND TETON DIAGNOSTICS CORP
Entity type:Organization
Organization Name:GRAND TETON DIAGNOSTICS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-954-7483
Mailing Address - Street 1:1701 N COLLINS BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3586
Mailing Address - Country:US
Mailing Address - Phone:214-954-7483
Mailing Address - Fax:214-258-5918
Practice Address - Street 1:1701 N COLLINS BLVD STE 1000
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3586
Practice Address - Country:US
Practice Address - Phone:214-954-7483
Practice Address - Fax:214-258-5916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-25
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory