Basic Information
| Provider Information | |||||||||
| NPI: | 1104349281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUNER | ||||||||
| FirstName: | ELISE | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4317 MOUNT VERNON PASS | ||||||||
| Address2: | |||||||||
| City: | SWARTZ CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484738240 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4500 S SAGINAW ST | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485072676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108936489 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2017 | ||||||||
| LastUpdateDate: | 07/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 7501010225 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.