Healthcare Provider Details

I. General information

NPI: 1083984280
Provider Name (Legal Business Name): JEREMIAH LEWIS GRANTHAM A.P. , LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 CAMINO GARDENS BLVD STE 203
BOCA RATON FL
33432-5827
US

IV. Provider business mailing address

398 CAMINO GARDENS BLVD STE 203
BOCA RATON FL
33432-5827
US

V. Phone/Fax

Practice location:
  • Phone: 561-212-1249
  • Fax:
Mailing address:
  • Phone: 561-212-1249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number2379
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: