=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851067599
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRENCE BRIAN GRYWINSKI LICENSED MASSAGE THE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2021
-----------------------------------------------------
Last Update Date | 08/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1188 N TAMIAMI TRL
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34236-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-321-8757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6419 MEANDERING WAY
-----------------------------------------------------
City | LAKEWOOD RANCH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34202-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-321-8757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172M00000X
-----------------------------------------------------
Taxonomy Name | Mechanotherapist
-----------------------------------------------------
License Number | MA6049
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------