=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073305611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARTER GRANT DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2025
-----------------------------------------------------
Last Update Date | 06/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 PEARL DR STE 104
-----------------------------------------------------
City | LA FAYETTE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30728-7510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-638-3880
-----------------------------------------------------
Fax | 706-638-3890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 528
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30162-0528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-528-4207
-----------------------------------------------------
Fax | 706-528-4211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT017739
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------