Healthcare Provider Details

I. General information

NPI: 1427788835
Provider Name (Legal Business Name): JOSEPH RICHARD GRYCH APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 SADDLEWOOD DR
BARTOW FL
33830-2914
US

IV. Provider business mailing address

2120 SADDLEWOOD DR
BARTOW FL
33830-2914
US

V. Phone/Fax

Practice location:
  • Phone: 813-210-6989
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11020082
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11020082
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: