1376785741 NPI number — MR. RAY ANTHONY GROSVELD RN

Table of content: MR. RAY ANTHONY GROSVELD RN (NPI 1376785741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376785741 NPI number — MR. RAY ANTHONY GROSVELD RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSVELD
Provider First Name:
RAY
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376785741
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
670 9TH ST STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCATA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95521-6249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-826-8633
Provider Business Mailing Address Fax Number:
707-826-8638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2426 BUHNE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95501-3207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-442-4038
Provider Business Practice Location Address Fax Number:
707-442-4039
Provider Enumeration Date:
04/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WP0809X , with the licence number:  712627 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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