1104976794 NPI number — GABRIEL ICF

Table of content: JENNIFER LYNN GRAU P.T., D.P.T. (NPI 1710363437)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104976794 NPI number — GABRIEL ICF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GABRIEL ICF
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104976794
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2216 ALPINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LODI
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95240-6703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-333-0592
Provider Business Mailing Address Fax Number:
209-368-2771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2155 W ELM STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LODI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95242-6703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-333-0592
Provider Business Practice Location Address Fax Number:
209-368-2771
Provider Enumeration Date:
01/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GABRIEL
Authorized Official First Name:
ELENA
Authorized Official Middle Name:
PAISTE
Authorized Official Title or Position:
ADMINISTRATOR RN
Authorized Official Telephone Number:
209-598-1436

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  LTC80160F , 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)

  • Identifier: LTC80160F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".