Provider Demographics
NPI:1538298419
Name:IANNELLI, GRANT CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:CHARLES
Last Name:IANNELLI
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 1:543 S FINLEY RD
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-2430
Mailing Address - Country:US
Mailing Address - Phone:630-640-5706
Mailing Address - Fax:630-477-0303
Practice Address - Street 1:543 S FINLEY RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2430
Practice Address - Country:US
Practice Address - Phone:630-640-5706
Practice Address - Fax:630-477-0303
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2013-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005170111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T38972Medicare UPIN
IL778331Medicare ID - Type Unspecified