Organization
GRAND TETON MEDICAL CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRENT BLUE M.D. (CLINIC OWNER)
(307) 733-8002
Entity
Organization
Contact information
Practice address
INNER LOOP ROAD, JACKSON LAKE LODGE, MORAN, WY 83013
(307) 543-2514
(307) 543-2514
Mailing address
PO BOX 15240, JACKSON, WY 83002-5240
(307) 733-8002
(307) 733-0032
Taxonomy
Speciality
Code
Description
License number
State
261QU0200X
Urgent Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1096516-00
—
WY
Enumeration date
05/31/2007
Last updated
08/02/2007
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