Healthcare Provider Details

I. General information

NPI: 1114235744
Provider Name (Legal Business Name): KENNETH GRIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18564 US HIGHWAY 18 STE 101
APPLE VALLEY CA
92307-2320
US

IV. Provider business mailing address

12277 APPLE VALLEY RD # 195
APPLE VALLEY CA
92308-1701
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-7777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA150771
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-16580
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: