Healthcare Provider Details

I. General information

NPI: 1457081978
Provider Name (Legal Business Name): BRANDT GRUIZINGA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

810 CHEYENNE ST
GOLDEN CO
80401-1037
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2000
  • Fax:
Mailing address:
  • Phone: 616-502-9581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberNA
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: