Provider Demographics
NPI:1467043646
Name:GRUNDER, EVAN WALTER (DC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:WALTER
Last Name:GRUNDER
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 1:1555 ANN ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-2606
Mailing Address - Country:US
Mailing Address - Phone:607-242-6913
Mailing Address - Fax:
Practice Address - Street 1:720 MONROE ST STE C208
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-6350
Practice Address - Country:US
Practice Address - Phone:201-535-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00777800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor