Healthcare Provider Details

I. General information

NPI: 1578977997
Provider Name (Legal Business Name): CASEY R GRAVES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92354
US

IV. Provider business mailing address

11234 ANDERSON ST
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4344
  • Fax:
Mailing address:
  • Phone: 909-558-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA159798
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberLL38088
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: