Provider Demographics
NPI:1003995127
Name:GRANT CHIROPRACTIC HEALTHCARE CENTER LLC
Entity Type:Organization
Organization Name:GRANT CHIROPRACTIC HEALTHCARE CENTER LLC
Other - Org Name:CAROL C GRANT DC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DC DACAN
Authorized Official - Phone:860-620-9523
Mailing Address - Street 1:1601 MERIDEN WATERBURY TPK
Mailing Address - Street 2:PO BOX 792
Mailing Address - City:MILLDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06473-0792
Mailing Address - Country:US
Mailing Address - Phone:860-620-9523
Mailing Address - Fax:860-620-9628
Practice Address - Street 1:1601 MERIDEN WATERBURY TPK
Practice Address - Street 2:
Practice Address - City:MILLDALE
Practice Address - State:CT
Practice Address - Zip Code:06473-0792
Practice Address - Country:US
Practice Address - Phone:860-620-9523
Practice Address - Fax:860-620-9628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT587111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050000587CT04OtherBLUE CROSS BLUE SHIELD
CT350000392Medicare ID - Type Unspecified
CT050000587CT04OtherBLUE CROSS BLUE SHIELD