Provider Demographics
NPI:1811938756
Name:GRISSO, WAYNE ALDEN III (DC)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ALDEN
Last Name:GRISSO
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:TRACE
Other - Middle Name:
Other - Last Name:GRISSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:10016 CHERRY HILL LN
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:76227-8550
Mailing Address - Country:US
Mailing Address - Phone:405-620-3147
Mailing Address - Fax:
Practice Address - Street 1:2200 MORRISS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-3598
Practice Address - Country:US
Practice Address - Phone:972-874-7554
Practice Address - Fax:972-874-7553
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR713593111N00000X
TX8761111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR651163168OtherTAX ID
OR116691Medicare ID - Type Unspecified
U87472Medicare UPIN