Healthcare Provider Details

I. General information

NPI: 1861803868
Provider Name (Legal Business Name): JUSTIN MICHAEL MELLIS-GRUBA C.P., C.O.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DOCTORS DR
ASHEVILLE NC
28801-4608
US

IV. Provider business mailing address

1 DOCTORS DR
ASHEVILLE NC
28801-4608
US

V. Phone/Fax

Practice location:
  • Phone: 828-254-3392
  • Fax: 828-254-4380
Mailing address:
  • Phone: 828-254-3392
  • Fax: 828-254-4380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: