Provider Demographics
NPI:1083060925
Name:FYFE, GREGORY (LMT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:FYFE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3386 BASSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3902
Mailing Address - Country:US
Mailing Address - Phone:231-421-9085
Mailing Address - Fax:
Practice Address - Street 1:2506 CROSSING CIR STE A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7955
Practice Address - Country:US
Practice Address - Phone:231-421-3333
Practice Address - Fax:231-421-3355
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501006113172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist