Provider Demographics
NPI:1285620757
Name:GRANOVSKY, LARISA (DC)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:GRANOVSKY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 RED LION RD
Mailing Address - Street 2:#5
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-1475
Mailing Address - Country:US
Mailing Address - Phone:215-464-0404
Mailing Address - Fax:215-464-0683
Practice Address - Street 1:842 RED LION RD
Practice Address - Street 2:#5
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-1475
Practice Address - Country:US
Practice Address - Phone:215-464-0404
Practice Address - Fax:215-464-0683
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-006295-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015288270001Medicaid
PA785173Medicare ID - Type Unspecified
PA0015288270001Medicaid