Provider Demographics
NPI:1174119903
Name:GRIVAS, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GRIVAS
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 1:6872 ANNA DR
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-5178
Mailing Address - Country:US
Mailing Address - Phone:734-731-1731
Mailing Address - Fax:
Practice Address - Street 1:6872 ANNA DR
Practice Address - Street 2:
Practice Address - City:VAN BUREN TWP
Practice Address - State:MI
Practice Address - Zip Code:48111-5178
Practice Address - Country:US
Practice Address - Phone:734-731-1731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010724225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist