Provider Demographics
NPI:1003391145
Name:MEDLOCK, GRANT
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:MEDLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2498 LYNN LAKE CIR S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-6117
Mailing Address - Country:US
Mailing Address - Phone:913-553-9394
Mailing Address - Fax:
Practice Address - Street 1:2498 LYNN LAKE CIR S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-6117
Practice Address - Country:US
Practice Address - Phone:913-553-9394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health