MEDICARE: JAMES COLIN GRADY LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MAS4960	ID
2	225700000X	Massage Therapist	MAS-4960	ID

General Provider Information

NPI Number	:	1649083635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES COLIN GRADY LMT

Provider Business Mailing Address
First Line	:	PO BOX 204
Second Line	:
City	:	SANTA
State	:	ID
Zip	:	83866-0204
Country	:	US
Telephone Number	:	208-295-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 EAST DAVIS STREET
Second Line	:
City	:	SANTA
State	:	ID
Zip	:	83866
Country	:	US
Telephone Number	:	208-295-9500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2025
Last Update Date	:	01/31/2025

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Directions to “ JAMES COLIN GRADY LMT” Practice Location

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