Provider Demographics
NPI:1730155334
Name:GRANDSTAFF, BRUCE JOHN SR (DC)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:JOHN
Last Name:GRANDSTAFF
Suffix:SR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7905 N MEADOWLARK WAY
Mailing Address - Street 2:STE B
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815
Mailing Address - Country:US
Mailing Address - Phone:208-772-6015
Mailing Address - Fax:208-772-6016
Practice Address - Street 1:7905 N MEADOWLARK WAY
Practice Address - Street 2:STE B
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815
Practice Address - Country:US
Practice Address - Phone:208-772-6015
Practice Address - Fax:208-772-6016
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA 668111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U38041Medicare UPIN
1672808Medicare ID - Type Unspecified