Healthcare Provider Details

I. General information

NPI: 1285070003
Provider Name (Legal Business Name): GERALD GRANT GWIN JR. LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10513 SILVERDALE WAY NW SUITE 101
SILVERDALE WA
98383-9499
US

IV. Provider business mailing address

5448 NW WESTGATE RD
SILVERDALE WA
98383-6834
US

V. Phone/Fax

Practice location:
  • Phone: 360-698-4411
  • Fax:
Mailing address:
  • Phone: 360-229-9882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60308827
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: