Provider Demographics
NPI:1770649311
Name:GRANT STREET CHIROPRACTIC PC
Entity Type:Organization
Organization Name:GRANT STREET CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-852-3396
Mailing Address - Street 1:206 GRANT STREET SW
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:IA
Mailing Address - Zip Code:52033-0456
Mailing Address - Country:US
Mailing Address - Phone:563-852-3396
Mailing Address - Fax:
Practice Address - Street 1:206 GRANT STREET SW
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:IA
Practice Address - Zip Code:52033-0456
Practice Address - Country:US
Practice Address - Phone:563-852-3396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6468111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0256768Medicaid
IAI17463Medicare PIN
IA0256768Medicaid