Provider Demographics
NPI:1962116202
Name:GRADISAR, LUC G (DC)
Entity type:Individual
Prefix:DR
First Name:LUC
Middle Name:G
Last Name:GRADISAR
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 OSCEOLA TRL
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-3135
Mailing Address - Country:US
Mailing Address - Phone:719-251-6154
Mailing Address - Fax:
Practice Address - Street 1:940 RIDGEVIEW DR STE 100
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5443
Practice Address - Country:US
Practice Address - Phone:972-521-6213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15447111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor