Provider Demographics
NPI:1023574373
Name:BARKER, GRANT BRADFORD
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:BRADFORD
Last Name:BARKER
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 1:201 S RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132
Mailing Address - Country:US
Mailing Address - Phone:386-423-7575
Mailing Address - Fax:386-423-8443
Practice Address - Street 1:201 S RIDGEWOOD AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132
Practice Address - Country:US
Practice Address - Phone:386-423-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12598111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor