Provider Demographics
NPI:1346863560
Name:GROENEWEG, DANIEL GRANT
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:GRANT
Last Name:GROENEWEG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13135 OLD GLENN HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7584
Mailing Address - Country:US
Mailing Address - Phone:907-696-9090
Mailing Address - Fax:907-696-9091
Practice Address - Street 1:13135 OLD GLENN HWY STE 100
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7584
Practice Address - Country:US
Practice Address - Phone:907-696-9090
Practice Address - Fax:907-696-9091
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK128196225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist