Provider Demographics
NPI:1528031093
Name:STOVALL, GRANT (ATC)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:
Last Name:STOVALL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1122
Mailing Address - Country:US
Mailing Address - Phone:806-790-1186
Mailing Address - Fax:
Practice Address - Street 1:LUBBOCK SPORTS MEDICINE ASSOCIATES
Practice Address - Street 2:4110 22ND PL
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410
Practice Address - Country:US
Practice Address - Phone:806-792-4329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11234122251S0007X
TXAT15162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB125034Medicare PIN
TXTXB125034Medicare Oscar/Certification