Provider Demographics
NPI:1083425854
Name:GRADAM MEN'S HEALTH TESTOSTERONE CLINIC LLC
Entity type:Organization
Organization Name:GRADAM MEN'S HEALTH TESTOSTERONE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:O
Authorized Official - Last Name:IMONAH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, DNP, FNP
Authorized Official - Phone:401-599-3737
Mailing Address - Street 1:225 NEWMAN AVE
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-1218
Mailing Address - Country:US
Mailing Address - Phone:401-599-3737
Mailing Address - Fax:401-409-5545
Practice Address - Street 1:225 NEWMAN AVE
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:RI
Practice Address - Zip Code:02916-1218
Practice Address - Country:US
Practice Address - Phone:401-599-3737
Practice Address - Fax:401-409-5545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center