Healthcare Provider Details

I. General information

NPI: 1619687084
Provider Name (Legal Business Name): JUSTS GRINVALDS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 SW 19TH AVENUE RD
OCALA FL
34471-1391
US

IV. Provider business mailing address

2230 SW 19TH AVENUE RD
OCALA FL
34471-1391
US

V. Phone/Fax

Practice location:
  • Phone: 352-237-4133
  • Fax: 352-237-7728
Mailing address:
  • Phone: 352-237-4133
  • Fax: 352-237-7728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11023270
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: