Healthcare Provider Details

I. General information

NPI: 1134140304
Provider Name (Legal Business Name): MARK JOSEPH GRANGER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4223 ORANGE BEACH BLVD SUITE D
ORANGE BEACH AL
36561-3459
US

IV. Provider business mailing address

1908 FLINT RD SE
DECATUR AL
35601-6031
US

V. Phone/Fax

Practice location:
  • Phone: 251-981-1300
  • Fax: 251-981-1305
Mailing address:
  • Phone: 256-340-9708
  • Fax: 256-340-9624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH3635
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: