Basic Information
| Provider Information | |||||||||
| NPI: | 1912508292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLER | ||||||||
| FirstName: | GRANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 REVERE DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600628005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478076647 | ||||||||
| FaxNumber: | 8473483706 | ||||||||
| Practice Location | |||||||||
| Address1: | 8008 E ARAPAHOE CT | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801126839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478076647 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2020 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-19-94756 | CO | Y |
No ID Information.