Provider Demographics
NPI:1114570249
Name:GREGGE, LAWRENCE JR (PTA)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:GREGGE
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25765 VIA HAMACA AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-2176
Mailing Address - Country:US
Mailing Address - Phone:951-212-4033
Mailing Address - Fax:
Practice Address - Street 1:900 SALEM DR
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-6189
Practice Address - Country:US
Practice Address - Phone:909-353-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA49768225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant