Provider Demographics
NPI:1265762017
Name:GRIGALTCHIK, TAMARA
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:
Last Name:GRIGALTCHIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12105 MADRID AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-1123
Mailing Address - Country:US
Mailing Address - Phone:941-423-0019
Mailing Address - Fax:941-423-0019
Practice Address - Street 1:12105 MADRID AVE
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-1123
Practice Address - Country:US
Practice Address - Phone:941-423-0019
Practice Address - Fax:941-423-0019
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906380171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider