Provider Demographics
NPI:1629189212
Name:GRISWOLD, STEPHEN R (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:GRISWOLD
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:PO BOX 636
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:GA
Mailing Address - Zip Code:31064
Mailing Address - Country:US
Mailing Address - Phone:706-468-6500
Mailing Address - Fax:706-468-6614
Practice Address - Street 1:111 WEST WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064
Practice Address - Country:US
Practice Address - Phone:706-468-6500
Practice Address - Fax:706-468-6614
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006912111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGSGMedicare ID - Type Unspecified
U89460Medicare UPIN