Healthcare Provider Details

I. General information

NPI: 1366794117
Provider Name (Legal Business Name): LORIE GRGURICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 BOSTWICK AVE
DAYTONA BEACH FL
32118-4808
US

IV. Provider business mailing address

344 BOSTWICK AVE
DAYTONA BEACH FL
32118-4808
US

V. Phone/Fax

Practice location:
  • Phone: 386-453-8001
  • Fax:
Mailing address:
  • Phone: 386-453-8001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT12134
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: