Healthcare Provider Details

I. General information

NPI: 1396146486
Provider Name (Legal Business Name): SVETLANA GRINBERG DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 10/31/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 LEBEC ROAD
LEBEC CA
93243
US

IV. Provider business mailing address

PO BOX 278
MADISONVILLE TN
37354-0278
US

V. Phone/Fax

Practice location:
  • Phone: 661-248-5250
  • Fax: 661-248-5279
Mailing address:
  • Phone: 423-442-2622
  • Fax: 423-442-5760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3527
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: