Provider Demographics
NPI:1073342333
Name:GRANT, DARRIS DARNELL
Entity type:Individual
Prefix:
First Name:DARRIS
Middle Name:DARNELL
Last Name:GRANT
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 1:1906 E BROADWAY AVE SUITE 1
Mailing Address - Street 2:1906 E BROADWAY AVE SUITE 1
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-516-3322
Mailing Address - Fax:
Practice Address - Street 1:1906 E BROADWAY AVE SUITE 1
Practice Address - Street 2:1906 E BROADWAY AVE SUITE 1
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-516-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDDUM00000171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator