Provider Demographics
NPI:1194057505
Name:GRONDEL URGENT CARE OF HENDERSON, PLLC
Entity type:Organization
Organization Name:GRONDEL URGENT CARE OF HENDERSON, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUINSMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-293-4769
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-0629
Mailing Address - Country:US
Mailing Address - Phone:515-645-9911
Mailing Address - Fax:515-967-5581
Practice Address - Street 1:10561 JEFFREYS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4266
Practice Address - Country:US
Practice Address - Phone:702-478-5620
Practice Address - Fax:702-478-5093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-10
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDG719AMedicare PIN