Provider Demographics
NPI:1851628283
Name:O'BRIEN, GRANT CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:CHARLES
Last Name:O'BRIEN
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 1:1224 E AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-2076
Mailing Address - Country:US
Mailing Address - Phone:612-655-0491
Mailing Address - Fax:
Practice Address - Street 1:200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2502
Practice Address - Country:US
Practice Address - Phone:920-720-6300
Practice Address - Fax:920-720-6315
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4582-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor