Provider Demographics
NPI:1982264487
Name:GRISBY, MELVIN EARL JR
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:EARL
Last Name:GRISBY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N92W17420 APPLETON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-1363
Mailing Address - Country:US
Mailing Address - Phone:262-732-7008
Mailing Address - Fax:262-735-7549
Practice Address - Street 1:N92W17420 APPLETON AVE STE 102
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-1363
Practice Address - Country:US
Practice Address - Phone:262-732-7008
Practice Address - Fax:262-735-7549
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health