Healthcare Provider Details

I. General information

NPI: 1477039667
Provider Name (Legal Business Name): MR. FREDERICK GRUBSTAD II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 BUCKMAN SPRINGS RD
CAMPO CA
91906-2022
US

IV. Provider business mailing address

14360 RIOS CANYON RD SPC 76
EL CAJON CA
92021-2735
US

V. Phone/Fax

Practice location:
  • Phone: 619-478-5696
  • Fax: 619-478-2404
Mailing address:
  • Phone: 619-249-3746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95019498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: