Provider Demographics
NPI:1619583689
Name:GRANTHAM, WILEY IV
Entity Type:Individual
Prefix:MR
First Name:WILEY
Middle Name:
Last Name:GRANTHAM
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 SE LILLIAN LOOP APT 103
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-7248
Mailing Address - Country:US
Mailing Address - Phone:386-965-7461
Mailing Address - Fax:
Practice Address - Street 1:560 SW MCFARLANE AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5614
Practice Address - Country:US
Practice Address - Phone:386-758-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26541225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant