Healthcare Provider Details

I. General information

NPI: 1982603502
Provider Name (Legal Business Name): JASON T. GRANDONE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 N KELLOGG ST
GALESBURG IL
61401-2875
US

IV. Provider business mailing address

765 N KELLOGG ST
GALESBURG IL
61401-2871
US

V. Phone/Fax

Practice location:
  • Phone: 309-343-3434
  • Fax: 309-343-3456
Mailing address:
  • Phone: 309-343-3434
  • Fax: 309-343-3456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070010049
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: