Provider Demographics
NPI:1194163592
Name:GRUMBINE, MARK J (CPED)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:GRUMBINE
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26127 74TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-6215
Mailing Address - Country:US
Mailing Address - Phone:360-631-8385
Mailing Address - Fax:360-926-8736
Practice Address - Street 1:2520 COLBY AVE
Practice Address - Street 2:#5
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2990
Practice Address - Country:US
Practice Address - Phone:360-320-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACPED3982174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist