Healthcare Provider Details

I. General information

NPI: 1073305611
Provider Name (Legal Business Name): CARTER GRANT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 PEARL DR STE 104
LA FAYETTE GA
30728-7510
US

IV. Provider business mailing address

PO BOX 528
ROME GA
30162-0528
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-3880
  • Fax: 706-638-3890
Mailing address:
  • Phone: 706-528-4207
  • Fax: 706-528-4211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017739
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: