Provider Demographics
NPI:1235151234
Name:GRUBB, MATTHEW THOMAS (LMT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:GRUBB
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 1:1206 SW MAIN BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6684
Mailing Address - Country:US
Mailing Address - Phone:386-719-2500
Mailing Address - Fax:386-719-2500
Practice Address - Street 1:1206 SW MAIN BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6684
Practice Address - Country:US
Practice Address - Phone:386-719-2500
Practice Address - Fax:386-719-2500
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA21745225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC8328OtherBLUE CROSS BLUE SHIELD PR