Organization
GRAPEVINE CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KAYE A CUNNINGHAM MD (OWNER/MEMBER)
(928) 788-6060
Entity
Organization
Contact information
Practice address
5300 S HIGHWAY 95, SUITE H, FORT MOHAVE, AZ 86426-9251
(928) 788-6060
(928) 788-6062
Mailing address
PO BOX 8670, FORT MOHAVE, AZ 86427-8670
(928) 788-6060
(928) 788-6062
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
28326
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
L-16288258
ARIZONA LLC REGISTRATION
AZ
Enumeration date
09/27/2010
Last updated
09/27/2010
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