# GRAPEVINE CLINIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1164731030
- **Authorized official:** KAYE A CUNNINGHAM MD (OWNER/MEMBER)
- **Authorized official phone:** (928) 788-6060

## Contact information

- **Practice address:** 5300 S HIGHWAY 95, SUITE H, FORT MOHAVE, AZ 86426-9251
- **Practice address phone:** (928) 788-6060
- **Practice address fax:** (928) 788-6062
- **Mailing address:** PO BOX 8670, FORT MOHAVE, AZ 86427-8670
- **Mailing address phone:** (928) 788-6060
- **Mailing address fax:** (928) 788-6062

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 28326 | AZ | Yes |

## Other

- **Enumeration date:** 09/27/2010
- **Last updated:** 09/27/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | L-16288258 | ARIZONA LLC REGISTRATION | AZ |