Provider Demographics
NPI:1346323474
Name:GRINE, EARL LAURENCE JR (PT, MSPT, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:EARL
Middle Name:LAURENCE
Last Name:GRINE
Suffix:JR
Gender:M
Credentials:PT, MSPT, ATC, CSCS
Other - Prefix:
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Mailing Address - Street 1:1634 AUTUMNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194-1522
Mailing Address - Country:US
Mailing Address - Phone:703-437-8011
Mailing Address - Fax:
Practice Address - Street 1:11800 SUNRISE VALLEY DR
Practice Address - Street 2:100
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191
Practice Address - Country:US
Practice Address - Phone:703-709-1116
Practice Address - Fax:703-709-5134
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202763225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC604546000OtherDEPARTMENT OF LABOR
VA172810OtherBLUE CROSS / BLUE SHIELD