Grand Teton Diagnostics Corp

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

Legal business name

GRAND TETON DIAGNOSTICS CORP

Practice address

1701 N Collins Blvd Ste 1000
Richardson, TX 75080-3586

Phone

(214) 954-7483

Fax

(214) 258-5916

NPI assigned

Oct 25, 2023

Last updated

Oct 31, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Justin Peterson

Title

Ceo

Phone

(214) 954-7483

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1698192000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698710400000",
    "number": "1023880861",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1701 N COLLINS BLVD STE 1000",
            "city": "RICHARDSON",
            "state": "TX",
            "postal_code": "750803586",
            "telephone_number": "214-954-7483",
            "fax_number": "214-258-5918"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1701 N COLLINS BLVD STE 1000",
            "city": "RICHARDSON",
            "state": "TX",
            "postal_code": "750803586",
            "telephone_number": "214-954-7483",
            "fax_number": "214-258-5916"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAND TETON DIAGNOSTICS CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-10-25",
        "last_updated": "2023-10-31",
        "certification_date": "2023-10-31",
        "status": "A",
        "authorized_official_last_name": "PETERSON",
        "authorized_official_first_name": "JUSTIN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "214-954-7483",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Philip Grandjean, M.S., LPC-A
• Sara Granger
• Reese Cabot Graves, MD
• Barbara Gray
• Olivia Gray, DPT

• Clinical Medical Laboratory in Richardson, TX
• Providers in Richardson, TX by specialty
• Clinical Medical Laboratory in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.