Provider Demographics
NPI:1487962015
Name:GRANT, CHARLES EDWARD JR (ATC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:GRANT
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 ANGEL CT
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-5562
Mailing Address - Country:US
Mailing Address - Phone:912-728-7511
Mailing Address - Fax:912-729-7529
Practice Address - Street 1:405 ANGEL CT
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5562
Practice Address - Country:US
Practice Address - Phone:912-728-7511
Practice Address - Fax:912-729-7529
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0011672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer