Provider Demographics
NPI:1265651350
Name:GOOLSBY, GRADY L (DC)
Entity type:Individual
Prefix:DR
First Name:GRADY
Middle Name:L
Last Name:GOOLSBY
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 1:317 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4817
Mailing Address - Country:US
Mailing Address - Phone:321-452-6264
Mailing Address - Fax:321-452-8935
Practice Address - Street 1:317 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4817
Practice Address - Country:US
Practice Address - Phone:321-452-6264
Practice Address - Fax:321-452-8935
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2808111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor