| Doctor Name: | MRS. TAMARA GRIGALTCHIK |
| NPI Number: | 1265762017 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 6906380 |
| Business Practice Address: | 12105 Madrid Ave North Port, FL - 342871123 |
| Business Phone Number: | 9414230019 |
| Business Fax Number: | 9414230019 |
| Mailing Address: | 12105 Madrid Ave, NORTH PORT |
| State: | FL |
| Postal Code: | 342871123 |
| Phone Number: | 9414230019 |
| Fax Number: | 9414230019 |
| NPI Enumeration Date: | 12/29/2009 |
| NPI Last Update Date: | 12/29/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171000000X |
| License Number: | 6906380 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Military Health Care Provider |
| Taxonomy Specialization: | |
| Taxonomy Definition: | Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes. |