Healthcare Provider Details

I. General information

NPI: 1942890918
Provider Name (Legal Business Name): ETHAN PATRICK-JAMES GRZEGORCZYK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date: 01/22/2021
Reactivation Date: 03/04/2021

III. Provider practice location address

1625 CONCENTRIC BLVD
SAGINAW MI
48604-9542
US

IV. Provider business mailing address

PO BOX 663
LAKELAND MI
48143-0663
US

V. Phone/Fax

Practice location:
  • Phone: 989-341-3653
  • Fax:
Mailing address:
  • Phone: 734-203-0181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: