Provider Demographics
NPI:1467086264
Name:AGRIAM, VIRGIL GLENN (LMT)
Entity Type:Individual
Prefix:MR
First Name:VIRGIL
Middle Name:GLENN
Last Name:AGRIAM
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 1:3841 E ESPLANADE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-5407
Mailing Address - Country:US
Mailing Address - Phone:602-430-9443
Mailing Address - Fax:
Practice Address - Street 1:85 W COMBS RD
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-9105
Practice Address - Country:US
Practice Address - Phone:480-816-7446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-19488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist