Healthcare Provider Details

I. General information

NPI: 1194554360
Provider Name (Legal Business Name): GRIND4FITNESS TRAINING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15651 W JACKSON ST
GOODYEAR AZ
85338-6701
US

IV. Provider business mailing address

15651 W JACKSON ST
GOODYEAR AZ
85338-6701
US

V. Phone/Fax

Practice location:
  • Phone: 773-967-0550
  • Fax:
Mailing address:
  • Phone: 773-967-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: KAYLA MARSHAE WILLIS
Title or Position: OWNER
Credential:
Phone: 773-967-0550