Provider Demographics
NPI:1780415141
Name:GRANGER, REGINALD (IDC)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:GRANGER
Suffix:
Gender:
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:OPC 561
Mailing Address - Street 2:BOX 15
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-9001
Mailing Address - Country:US
Mailing Address - Phone:315-255-8388
Mailing Address - Fax:
Practice Address - Street 1:OPC 561
Practice Address - Street 2:BOX 15
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96310-9001
Practice Address - Country:US
Practice Address - Phone:315-255-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman