Provider Demographics
NPI:1568446615
Name:GRANT, GAVIN LESTER (DC)
Entity Type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:LESTER
Last Name:GRANT
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 1:1400 BRISTOL ST N
Mailing Address - Street 2:#170
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2911
Mailing Address - Country:US
Mailing Address - Phone:949-851-5119
Mailing Address - Fax:949-851-6269
Practice Address - Street 1:1400 BRISTOL ST N
Practice Address - Street 2:#170
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2911
Practice Address - Country:US
Practice Address - Phone:949-851-5119
Practice Address - Fax:949-851-6269
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24812111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC024812OtherBLUE SHIELD PROVIDER
CADC024812OtherBLUE SHIELD PROVIDER