Healthcare Provider Details

I. General information

NPI: 1215190459
Provider Name (Legal Business Name): RECTAL RELIEF CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13005 SOUTHERN BLVD STE 122 SUITE 122 MEDICAL MALL ONE
LOXAHATCHEE FL
33470-9231
US

IV. Provider business mailing address

13005 SOUTHERN BLVD STE 122 SUITE 122 MEDICAL MALL ONE
LOXAHATCHEE FL
33470-9231
US

V. Phone/Fax

Practice location:
  • Phone: 561-842-5050
  • Fax: 561-793-9989
Mailing address:
  • Phone: 561-842-5050
  • Fax: 561-793-9989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP3357122
License Number StateFL

VIII. Authorized Official

Name: MS. SHERI SHANNON GRISSO
Title or Position: PRESIDENT
Credential: ARNP
Phone: 561-842-5050