MEDICARE: DAVID EDWARD GRISE ATC, OTC, R.T. (R)

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2255A2300X	Athletic Trainer
2	247100000X	Radiologic Technologist
3	2471C3402X	Radiography Radiologic Technologist

General Provider Information

NPI Number	:	1144771148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID EDWARD GRISE ATC, OTC, R.T. (R)

Provider Business Mailing Address
First Line	:	3136 W MALDONADO RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6371
Country	:	US
Telephone Number	:	480-518-5552
Fax Number	:

Provider Business Practice Location Address
First Line	:	3136 W MALDONADO RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-6371
Country	:	US
Telephone Number	:	480-518-5552
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2016
Last Update Date	:	10/14/2016

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