Healthcare Provider Details

I. General information

NPI: 1881435113
Provider Name (Legal Business Name): MR. JAVIROUS DEVONTAY GRANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 RIVERWOOD PKWY SE STE 1900
ATLANTA GA
30339-2066
US

IV. Provider business mailing address

3164 PARTRIDGE RD
MONTGOMERY AL
36111-3022
US

V. Phone/Fax

Practice location:
  • Phone: 334-221-8808
  • Fax:
Mailing address:
  • Phone: 334-221-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2854
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: