Provider Demographics
NPI:1770970667
Name:BARGENDER, GRANT LOUIS (LAT, ATC)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:LOUIS
Last Name:BARGENDER
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 274
Mailing Address - Street 2:112 E MAPLE ST
Mailing Address - City:EDGAR
Mailing Address - State:WI
Mailing Address - Zip Code:54426-0274
Mailing Address - Country:US
Mailing Address - Phone:715-507-1151
Mailing Address - Fax:
Practice Address - Street 1:1500 S. UNIVERSITY PARKS DR
Practice Address - Street 2:BAYLOR ATHLETIC TRAINING
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706
Practice Address - Country:US
Practice Address - Phone:715-507-1151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-19
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT63302255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer