Provider Demographics
NPI:1215381520
Name:GRANT, MARCUS
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:GRANT
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:PO BOX 674
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-0674
Mailing Address - Country:US
Mailing Address - Phone:321-222-0172
Mailing Address - Fax:888-859-2513
Practice Address - Street 1:1380 S DELEON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7749
Practice Address - Country:US
Practice Address - Phone:321-222-0172
Practice Address - Fax:888-859-2513
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator