Provider Demographics
NPI:1184818767
Name:GRANT, ANTONIO MAURICIO I (MASTER ACCOUNTING)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:MAURICIO
Last Name:GRANT
Suffix:I
Gender:M
Credentials:MASTER ACCOUNTING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 VETERANS MEMORIAL HWY SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-3111
Mailing Address - Country:US
Mailing Address - Phone:678-887-0752
Mailing Address - Fax:
Practice Address - Street 1:1337 VETERANS MEMORIAL HWY SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-3111
Practice Address - Country:US
Practice Address - Phone:678-887-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)