Healthcare Provider Details

I. General information

NPI: 1427740364
Provider Name (Legal Business Name): MR. NICHOLAS DAVID GROTJOHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5881 NW 16TH PL APT 219
SUNRISE FL
33313-4776
US

IV. Provider business mailing address

11110 W OAKLAND PARK BLVD STE 376
SUNRISE FL
33351-6808
US

V. Phone/Fax

Practice location:
  • Phone: 954-297-7369
  • Fax:
Mailing address:
  • Phone: 954-297-7369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberW473363
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: