1578112686 NPI number — HENRY DEWAYNE GRANDBERRY

Table of content: DR. CAM-HOUNG TRINH D.D.S. (NPI 1912067166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578112686 NPI number — HENRY DEWAYNE GRANDBERRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANDBERRY
Provider First Name:
HENRY
Provider Middle Name:
DEWAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1578112686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 845
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71366-0845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-535-4756
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 HANCOCK
Provider Second Line Business Practice Location Address:
501 HANCOCK
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-535-4756
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2019

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: 225XR0403X , with the licence number:  NA , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NA , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: NA . This is a "NA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com