Healthcare Provider Details

I. General information

NPI: 1184727059
Provider Name (Legal Business Name): GRIDLEY MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SPRUCE ST
GRIDLEY CA
95948-2215
US

IV. Provider business mailing address

225 SPRUCE ST
GRIDLEY CA
95948-2215
US

V. Phone/Fax

Practice location:
  • Phone: 530-846-5655
  • Fax: 530-846-3784
Mailing address:
  • Phone: 530-846-5655
  • Fax: 530-846-3784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5317
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TERRY LYNN MAGUIRE
Title or Position: ADMINISTRATIVE ASSIST
Credential:
Phone: 530-332-6021