Provider Demographics
NPI:1588046031
Name:GRANT, CHELSEA (OD)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:525 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060
Practice Address - Country:US
Practice Address - Phone:317-776-0036
Practice Address - Fax:317-774-9283
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201294640Medicaid
IN160450045Medicare PIN
IN201294640Medicaid