Healthcare Provider Details

I. General information

NPI: 1780650259
Provider Name (Legal Business Name): MARK E GRIECO X-RAY TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USCG HQ, COMDT (CG-1122) 2100 2ND STREET, RM 5314
WASHINGTON DC
20593-0001
US

IV. Provider business mailing address

219 CHARTER OAK DR
GROTON CT
06340-2934
US

V. Phone/Fax

Practice location:
  • Phone: 860-444-8402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: