MEDICARE: GRAND PHYSICAL THERAPY CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1215493200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND PHYSICAL THERAPY CO

Provider Business Mailing Address
First Line	:	6773 S WATERWAY DR
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-3743
Country	:	US
Telephone Number	:	786-901-1236
Fax Number	:	786-364-0217

Provider Business Practice Location Address
First Line	:	5200 SW 8TH ST STE 202B
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-2337
Country	:	US
Telephone Number	:	786-901-1236
Fax Number	:	786-364-0217

Authorized Official
Title or Position	:	CEO
Name	:	MURIEL EMILCE GONZALEZ GRANDOLI
Credential	:	MPT
Telephone Number	:	786-901-1236

Provider Enumeration Date	:	02/14/2019
Last Update Date	:	08/07/2019

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