Provider Demographics
NPI:1174945521
Name:DALE P GREYSLAK PA PLLC
Entity type:Organization
Organization Name:DALE P GREYSLAK PA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:GREYSLAK
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:407-451-0192
Mailing Address - Street 1:PO BOX 410185
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32941-0185
Mailing Address - Country:US
Mailing Address - Phone:407-451-0192
Mailing Address - Fax:
Practice Address - Street 1:3491 TITANIC CIR
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-1871
Practice Address - Country:US
Practice Address - Phone:407-451-0192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-19
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104508363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty