Healthcare Provider Details

I. General information

NPI: 1023062171
Provider Name (Legal Business Name): GRASS VALLEY CARDIOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 CATHERINE LANE D
GRASS VALLEY CA
95945
US

IV. Provider business mailing address

150 CATHERINE LN SUITE D
GRASS VALLEY CA
95945-5719
US

V. Phone/Fax

Practice location:
  • Phone: 530-477-8358
  • Fax: 530-477-2015
Mailing address:
  • Phone: 530-477-8358
  • Fax: 530-477-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. NANCY L BENTON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 530-477-7265