Provider Demographics
NPI:1245211267
Name:CARTER, GRADY L (DC)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:L
Last Name:CARTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-6411
Mailing Address - Country:US
Mailing Address - Phone:904-358-8692
Mailing Address - Fax:904-354-7161
Practice Address - Street 1:4211 N PEARL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-6411
Practice Address - Country:US
Practice Address - Phone:904-358-8692
Practice Address - Fax:904-354-7161
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH2947111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT85830Medicare UPIN
FL88239Medicare ID - Type Unspecified