Provider Demographics
NPI:1730631961
Name:FERGUSON, GRANT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:FERGUSON
Suffix:
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 1:423 NE 4TH ST
Mailing Address - Street 2:1
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2968
Mailing Address - Country:US
Mailing Address - Phone:218-326-8283
Mailing Address - Fax:
Practice Address - Street 1:423 NE 4TH ST
Practice Address - Street 2:1
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2968
Practice Address - Country:US
Practice Address - Phone:218-326-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6282111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor