MEDICARE: MR. BRYON GRAULICH ATC, 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	AT 3266	CA
2	2255A2300X	Athletic Trainer	508124013	CA

General Provider Information

NPI Number	:	1770982514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYON GRAULICH ATC, PTA

Provider Business Mailing Address
First Line	:	5233 E KEYNOTE ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-2526
Country	:	US
Telephone Number	:	949-533-5667
Fax Number	:

Provider Business Practice Location Address
First Line	:	5233 E KEYNOTE ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-2526
Country	:	US
Telephone Number	:	949-533-5667
Fax Number	:

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

Provider Enumeration Date	:	08/18/2014
Last Update Date	:	08/18/2014

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