Provider Demographics
NPI:1770939159
Name:LARIE, GRANT (DC)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:LARIE
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 1:502 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2714
Mailing Address - Country:US
Mailing Address - Phone:920-337-0103
Mailing Address - Fax:920-338-9066
Practice Address - Street 1:502 GEORGE ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2714
Practice Address - Country:US
Practice Address - Phone:920-337-0103
Practice Address - Fax:920-338-9066
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5174-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor