Provider Demographics
NPI:1932841376
Name:RIVERA, GRANT VIDAL (DC)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:VIDAL
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:GRANT
Other - Middle Name:VIDAL
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6830 POPPY HILLS LN APT 1235
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-8563
Mailing Address - Country:US
Mailing Address - Phone:305-528-5755
Mailing Address - Fax:
Practice Address - Street 1:9864 REA RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6792
Practice Address - Country:US
Practice Address - Phone:980-339-3058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36215111N00000X
NC5665111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor