Provider Demographics
NPI:1780914929
Name:GRANT CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:GRANT CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-851-5119
Mailing Address - Street 1:1400 BRISTOL ST N
Mailing Address - Street 2:#170
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2911
Mailing Address - Country:US
Mailing Address - Phone:949-851-5119
Mailing Address - Fax:949-851-6269
Practice Address - Street 1:1400 BRISTOL ST N
Practice Address - Street 2:#170
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2911
Practice Address - Country:US
Practice Address - Phone:949-851-5119
Practice Address - Fax:949-851-6269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24812111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty