Healthcare Provider Details

I. General information

NPI: 1912814583
Provider Name (Legal Business Name): IAN GRAPE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 W COMMUNITY DR
MUNCIE IN
47304-5457
US

IV. Provider business mailing address

3300 W COMMUNITY DR
MUNCIE IN
47304-5457
US

V. Phone/Fax

Practice location:
  • Phone: 765-751-2555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number05016268A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: