1114098217 NPI number — MR. GRANT LOUIS COLGARY JR. OPTICIAN

Table of content: MR. GRANT LOUIS COLGARY JR. OPTICIAN (NPI 1114098217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114098217 NPI number — MR. GRANT LOUIS COLGARY JR. OPTICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLGARY
Provider First Name:
GRANT
Provider Middle Name:
LOUIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
OPTICIAN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLGARY
Provider Other First Name:
FLORENCE
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OPTICIAN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1114098217
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
261 JAMES ST
Provider Second Line Business Mailing Address:
SUITE 1B
Provider Business Mailing Address City Name:
MORRISTOWN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07960-6392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-285-1566
Provider Business Mailing Address Fax Number:
973-285-4806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
261 JAMES ST
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
MORRISTOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07960-6392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-285-1566
Provider Business Practice Location Address Fax Number:
973-285-4806
Provider Enumeration Date:
11/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  D969 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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