Provider Demographics
NPI:1295468239
Name:GRANT, GARY
Entity Type:Individual
Prefix:
First Name:GARY
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 1:1870 PORTERS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5797
Mailing Address - Country:US
Mailing Address - Phone:601-529-6750
Mailing Address - Fax:
Practice Address - Street 1:870 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-5695
Practice Address - Country:US
Practice Address - Phone:601-786-3401
Practice Address - Fax:601-786-3400
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist