Healthcare Provider Details

I. General information

NPI: 1114209004
Provider Name (Legal Business Name): DONNA JO GRANT LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 MAIN ST SW
LOS LUNAS NM
87031-8766
US

IV. Provider business mailing address

2 BERBEN RD
LOS LUNAS NM
87031-7113
US

V. Phone/Fax

Practice location:
  • Phone: 505-504-3861
  • Fax:
Mailing address:
  • Phone: 505-916-6708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6926
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: