MEDICARE: STEPHEN GROSSERODE DPT

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	2251X0800X	Orthopedic Physical Therapist	36953	CA

General Provider Information

NPI Number	:	1659681997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN GROSSERODE DPT

Provider Business Mailing Address
First Line	:	808 4TH ST APT 212
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-1229
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	488 S SAN VICENTE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4107
Country	:	US
Telephone Number	:	323-655-9055
Fax Number	:

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

Provider Enumeration Date	:	10/20/2010
Last Update Date	:	03/19/2013

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Directions to “ STEPHEN GROSSERODE DPT” Practice Location

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