Provider Demographics
NPI:1396271458
Name:BOMKAMP, GRANT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:BOMKAMP
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:PO BOX 441146
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30160-9522
Mailing Address - Country:US
Mailing Address - Phone:678-459-3745
Mailing Address - Fax:678-567-6737
Practice Address - Street 1:30 S NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-6231
Practice Address - Country:US
Practice Address - Phone:224-218-2984
Practice Address - Fax:224-836-5354
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist