Healthcare Provider Details

I. General information

NPI: 1306600861
Provider Name (Legal Business Name): GRACIE KRUGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15367 W MCDOWELL RD
GOODYEAR AZ
85395-2576
US

IV. Provider business mailing address

20387 W THAYER ST
BUCKEYE AZ
85396-3548
US

V. Phone/Fax

Practice location:
  • Phone: 602-448-5792
  • Fax:
Mailing address:
  • Phone: 602-448-5792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: