MEDICARE: DEZANIQ GRANTHAM

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1881418762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEZANIQ GRANTHAM

Provider Business Mailing Address
First Line	:	PO BOX 337
Second Line	:
City	:	SANDUSKY
State	:	OH
Zip	:	44871-0337
Country	:	US
Telephone Number	:	567-290-2658
Fax Number	:	567-246-2424

Provider Business Practice Location Address
First Line	:	4317 ST RT 269 S
Second Line	:
City	:	CASTALIA
State	:	OH
Zip	:	44824-9354
Country	:	US
Telephone Number	:	567-290-2658
Fax Number	:	567-246-2424

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

Provider Enumeration Date	:	11/08/2024
Last Update Date	:	11/08/2024

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Directions to “ DEZANIQ GRANTHAM ” Practice Location

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