Provider Demographics
NPI:1275679573
Name:GRANT, MARY SHANNON (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SHANNON
Last Name:GRANT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:SHANNON
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:340 S FARRELL DR
Mailing Address - Street 2:SUITE A110
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-7963
Mailing Address - Country:US
Mailing Address - Phone:760-322-9310
Mailing Address - Fax:760-322-9313
Practice Address - Street 1:340 S FARRELL DR
Practice Address - Street 2:SUITE A110
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-7963
Practice Address - Country:US
Practice Address - Phone:760-322-9310
Practice Address - Fax:760-322-9313
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29505111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor