Healthcare Provider Details

I. General information

NPI: 1538298419
Provider Name (Legal Business Name): GRANT CHARLES IANNELLI DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 05/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 S FINLEY RD
LOMBARD IL
60148-2430
US

IV. Provider business mailing address

543 S FINLEY RD
LOMBARD IL
60148-2430
US

V. Phone/Fax

Practice location:
  • Phone: 630-640-5706
  • Fax: 630-477-0303
Mailing address:
  • Phone: 630-640-5706
  • Fax: 630-477-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number038005170
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: