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General NPI Number Information
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NPI Number | 1962654160
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Entity Type | Individual
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Provider Name | LISA BRADY GRANT DC
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Gender | Female
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Dates
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Enumeration Date | 10/21/2008
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Last Update Date | 10/21/2008
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Provider Practice Location Address
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Address Line | 290 W. KELLY ST.
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City | JACKSON
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State | WY
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Zip | 83001
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Country | US
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Telephone | 307-739-0553
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1426
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City | WILSON
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State | WY
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Zip | 83014-1426
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Country | US
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Telephone | 307-739-0553
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 510
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License Number State | WY
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