Provider Demographics
NPI:1831554773
Name:GRADY, TIMOTHY (DC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:GRADY
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 1:206 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-1617
Mailing Address - Country:US
Mailing Address - Phone:616-523-6697
Mailing Address - Fax:616-523-6698
Practice Address - Street 1:206 W MAIN ST
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-1617
Practice Address - Country:US
Practice Address - Phone:616-523-6697
Practice Address - Fax:616-523-6698
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010333111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI20160212358398Medicaid