1144994088 NPI number — SHAWN LEE GRUCELLA CPHT

Table of content: SHAWN LEE GRUCELLA CPHT (NPI 1144994088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144994088 NPI number — SHAWN LEE GRUCELLA CPHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRUCELLA
Provider First Name:
SHAWN
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144994088
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11652 PHEASANT DR SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FIFE LAKE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49633-9055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-744-6425
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 N CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALKASKA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49646-8061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-258-2081
Provider Business Practice Location Address Fax Number:
231-258-5883
Provider Enumeration Date:
08/04/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183700000X , with the licence number:  5303028132 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5303028132 . This is a "STATE CERTIFICATION NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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