Organization
GRAND CANYON LAB LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. THEO BLAISE RUKUNDO PHARMD, MBA (MANAGING DIRECTOR)
(857) 247-8763
Entity
Organization
Contact information
Practice address
4141 N 32ND ST STE 102, PHOENIX, AZ 85018-4775
(857) 247-8763
Mailing address
4141 N 32ND ST STE 102, PHOENIX, AZ 85018-4775
(857) 247-8763
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
—
Other
Enumeration date
04/10/2023
Last updated
04/10/2023
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