Healthcare Provider Details

I. General information

NPI: 1336779909
Provider Name (Legal Business Name): MICHELLE LEE GRGUROVICH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13361 PIEDMONT VISTA DR
HAYMARKET VA
20169-2658
US

IV. Provider business mailing address

13361 PIEDMONT VISTA DR
HAYMARKET VA
20169-2658
US

V. Phone/Fax

Practice location:
  • Phone: 516-319-4017
  • Fax:
Mailing address:
  • Phone: 516-319-4017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604028
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: