Basic Information
| Provider Information | |||||||||
| NPI: | 1073918959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRILLO | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11240 WAPLES MILL RD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220306078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038383645 | ||||||||
| FaxNumber: | 7038105494 | ||||||||
| Practice Location | |||||||||
| Address1: | 13350 FRANKLIN FARM RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HERNDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201714091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038105205 | ||||||||
| FaxNumber: | 7038105494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 11/04/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305209127 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.