Provider Demographics
NPI:1508385600
Name:GRANA, JUAN C (DC)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:C
Last Name:GRANA
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 1:35 MARY ELLEN DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1108
Mailing Address - Country:US
Mailing Address - Phone:908-591-3882
Mailing Address - Fax:
Practice Address - Street 1:1115 GLOBE AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAINSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07092-2903
Practice Address - Country:US
Practice Address - Phone:908-561-8888
Practice Address - Fax:908-222-3481
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18202261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0153371Medicaid
NJ0540471Medicaid