Provider Demographics
NPI:1710981568
Name:WILLIAMS, GRANT L (DC)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:L
Last Name:WILLIAMS
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 1:832 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1374
Mailing Address - Country:US
Mailing Address - Phone:608-375-5100
Mailing Address - Fax:
Practice Address - Street 1:832 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1374
Practice Address - Country:US
Practice Address - Phone:608-375-5100
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3150111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38898100Medicaid
WIU52722Medicare UPIN