MEDICARE: DAYLON GRANDBERRY

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1790239838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAYLON GRANDBERRY

Provider Business Mailing Address
First Line	:	1200 SAVAGE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-1638
Country	:	US
Telephone Number	:	817-401-8115
Fax Number	:	469-586-4842

Provider Business Practice Location Address
First Line	:	1200 SAVAGE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-1638
Country	:	US
Telephone Number	:	817-401-8115
Fax Number	:	469-586-4842

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

Provider Enumeration Date	:	08/06/2016
Last Update Date	:	08/06/2016

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Directions to “ DAYLON GRANDBERRY ” Practice Location

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