MEDICARE: ALICE KAY GROHOSKE PTA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA 20742	FL

General Provider Information

NPI Number	:	1619148111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICE KAY GROHOSKE PTA

Provider Business Mailing Address
First Line	:	1153 GULF BREEZE PKWY
Second Line	:
City	:	GULF BREEZE
State	:	FL
Zip	:	32561-4835
Country	:	US
Telephone Number	:	850-932-6382
Fax Number	:	850-932-9215

Provider Business Practice Location Address
First Line	:	450 RACETRACK RD NW
Second Line	:	SUITE G
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-3837
Country	:	US
Telephone Number	:	850-863-4698
Fax Number	:	850-863-8580

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

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	03/12/2008

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