Provider Demographics
NPI:1760836308
Name:SAGUM, GRANT (LAC)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:SAGUM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6059 S QUEBEC ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80111-4514
Mailing Address - Country:US
Mailing Address - Phone:303-773-1166
Mailing Address - Fax:
Practice Address - Street 1:6059 S QUEBEC ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-4514
Practice Address - Country:US
Practice Address - Phone:303-773-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002187171100000X
WI867-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist