Provider Demographics
NPI:1215654322
Name:GRANT, MATT WALTER
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:WALTER
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 1:1356 SPENCERVILLE HICKSVILL RD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43526-9712
Mailing Address - Country:US
Mailing Address - Phone:419-769-4348
Mailing Address - Fax:
Practice Address - Street 1:1356 SPENCERVILLE HICKSVILL RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43526-9712
Practice Address - Country:US
Practice Address - Phone:419-769-4348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant