Healthcare Provider Details

I. General information

NPI: 1659353951
Provider Name (Legal Business Name): JOHN ROBERT GRANT DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 E FIRST ST
BLUE RIDGE GA
30513-4510
US

IV. Provider business mailing address

2710 E FIRST ST
BLUE RIDGE GA
30513-4510
US

V. Phone/Fax

Practice location:
  • Phone: 706-632-6574
  • Fax: 706-632-6527
Mailing address:
  • Phone: 706-632-6574
  • Fax: 706-632-6527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3032
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: