Healthcare Provider Details

I. General information

NPI: 1750485041
Provider Name (Legal Business Name): GORDON GREGORY GRANT IV DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 HWY 165 N
MONROE LA
71203-2519
US

IV. Provider business mailing address

3219 HWY 165 N
MONROE LA
71203-2519
US

V. Phone/Fax

Practice location:
  • Phone: 318-387-5388
  • Fax: 318-325-9882
Mailing address:
  • Phone: 318-387-5388
  • Fax: 318-325-9882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1397
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: