Healthcare Provider Details

I. General information

NPI: 1851067599
Provider Name (Legal Business Name): TERRENCE BRIAN GRYWINSKI LICENSED MASSAGE THE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 N TAMIAMI TRL
SARASOTA FL
34236-2414
US

IV. Provider business mailing address

6419 MEANDERING WAY
LAKEWOOD RANCH FL
34202-1864
US

V. Phone/Fax

Practice location:
  • Phone: 941-321-8757
  • Fax:
Mailing address:
  • Phone: 941-321-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA6049
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: