Provider Demographics
NPI:1417509902
Name:GROGGINS, ALONZO GERRARD (ATC, AT)
Entity Type:Individual
Prefix:
First Name:ALONZO
Middle Name:GERRARD
Last Name:GROGGINS
Suffix:
Gender:M
Credentials:ATC, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20434 KLINGER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1746
Mailing Address - Country:US
Mailing Address - Phone:313-308-7195
Mailing Address - Fax:
Practice Address - Street 1:13800 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3296
Practice Address - Country:US
Practice Address - Phone:313-308-7195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010013802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer