Healthcare Provider Details

I. General information

NPI: 1255793261
Provider Name (Legal Business Name): ARIE DEGRIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 GOLF COURSE RD
GRAND RAPIDS MN
55744-8648
US

IV. Provider business mailing address

1601 GOLF COURSE RD
GRAND RAPIDS MN
55744-8648
US

V. Phone/Fax

Practice location:
  • Phone: 218-999-1442
  • Fax: 218-999-1461
Mailing address:
  • Phone: 218-999-1442
  • Fax: 218-999-1461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number54825
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number66357
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: