1750653572 NPI number — DENA DELVARON GRANGER D.C.

Table of content: DENA DELVARON GRANGER D.C. (NPI 1750653572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750653572 NPI number — DENA DELVARON GRANGER D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANGER
Provider First Name:
DENA
Provider Middle Name:
DELVARON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750653572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
76 TABB DRIVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
MUNFORD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-840-2234
Provider Business Mailing Address Fax Number:
901-840-2237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3615 S HOUSTON LEVEE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLIERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38017-9192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-221-7173
Provider Business Practice Location Address Fax Number:
901-221-7934
Provider Enumeration Date:
02/09/2012

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: 111N00000X , with the licence number:  2675 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q025029 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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