Healthcare Provider Details

I. General information

NPI: 1265762017
Provider Name (Legal Business Name): MRS. TAMARA GRIGALTCHIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12105 MADRID AVE
NORTH PORT FL
34287-1123
US

IV. Provider business mailing address

12105 MADRID AVE
NORTH PORT FL
34287-1123
US

V. Phone/Fax

Practice location:
  • Phone: 941-423-0019
  • Fax: 941-423-0019
Mailing address:
  • Phone: 941-423-0019
  • Fax: 941-423-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number6906380
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: