Healthcare Provider Details

I. General information

NPI: 1073051223
Provider Name (Legal Business Name): LWBBA GRISSELL CHAIT LLAMAS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 W LEGION RD SUITE 103
BRAWLEY CA
92227-7732
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 760-351-4100
  • Fax: 760-351-4101
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA138938
License Number StateCA

VIII. Authorized Official

Name: LWBBA GRISSELL CHAIT LLAMAS
Title or Position: OWNER
Credential: MD
Phone: 760-351-3333