Provider Demographics
NPI:1790547990
Name:HOLST-GRUBBE, NATHAN REIDAR
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:REIDAR
Last Name:HOLST-GRUBBE
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 1:141 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-6024
Mailing Address - Country:US
Mailing Address - Phone:475-233-4445
Mailing Address - Fax:
Practice Address - Street 1:141 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6024
Practice Address - Country:US
Practice Address - Phone:475-233-4445
Practice Address - Fax:207-755-3445
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME20000543262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer