Provider Demographics
NPI:1659353951
Name:GRANT, JOHN ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
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 1:2710 E FIRST ST
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4510
Mailing Address - Country:US
Mailing Address - Phone:706-632-6574
Mailing Address - Fax:706-632-6527
Practice Address - Street 1:2710 E FIRST ST
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4510
Practice Address - Country:US
Practice Address - Phone:706-632-6574
Practice Address - Fax:706-632-6527
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3032111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000767335AMedicaid
GAU42712Medicare UPIN
GA000767335AMedicaid