Provider Demographics
NPI:1942411699
Name:PEACOCK, GRANT ALLEN III (PT)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:ALLEN
Last Name:PEACOCK
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 CHURCHWELL LN
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2412
Mailing Address - Country:US
Mailing Address - Phone:770-491-8511
Mailing Address - Fax:770-491-6914
Practice Address - Street 1:2627 CHURCHWELL LN
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-2412
Practice Address - Country:US
Practice Address - Phone:770-491-8511
Practice Address - Fax:770-491-6914
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT001863174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist