Provider Demographics
NPI:1083984280
Name:GRANTHAM, JEREMIAH LEWIS (AP , LMT)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:LEWIS
Last Name:GRANTHAM
Suffix:
Gender:M
Credentials:AP , LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 CAMINO GARDENS BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-5827
Mailing Address - Country:US
Mailing Address - Phone:561-212-1249
Mailing Address - Fax:
Practice Address - Street 1:398 CAMINO GARDENS BLVD STE 203
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-5827
Practice Address - Country:US
Practice Address - Phone:561-212-1249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2379171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist