Healthcare Provider Details

I. General information

NPI: 1114458114
Provider Name (Legal Business Name): MOLLY GRASSINI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST CLINIC TOWER, SUITE A7D
LOS ANGELES CA
90033-1029
US

IV. Provider business mailing address

1200 N STATE ST OFC 1011
LOS ANGELES CA
90089-1001
US

V. Phone/Fax

Practice location:
  • Phone: 818-632-8101
  • Fax:
Mailing address:
  • Phone: 818-632-8101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA157859
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: