Provider Demographics
NPI:1568405074
Name:GRANDIZIO, JOHN M (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:GRANDIZIO
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 1:215 W 4TH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:QUARRYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17566-1135
Mailing Address - Country:US
Mailing Address - Phone:717-786-3300
Mailing Address - Fax:717-464-9078
Practice Address - Street 1:215 W 4TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:QUARRYVILLE
Practice Address - State:PA
Practice Address - Zip Code:17566-1135
Practice Address - Country:US
Practice Address - Phone:717-786-3300
Practice Address - Fax:717-464-9078
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-005800-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA610537Medicare ID - Type Unspecified