Healthcare Provider Details

I. General information

NPI: 1881245967
Provider Name (Legal Business Name): GRANT M GOLOMBESKI IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S TWINNING DR.
APO AA
36112
US

IV. Provider business mailing address

85 WAXWING DR
POTEET TX
78065-4581
US

V. Phone/Fax

Practice location:
  • Phone: 850-797-4859
  • Fax:
Mailing address:
  • Phone: 850-797-4859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: