Healthcare Provider Details

I. General information

NPI: 1639166028
Provider Name (Legal Business Name): MICHAEL FREDERICK GRISWOLD RNFA CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICK F GRISWOLD RNFA CNS

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72780 COUNTRY CLUB DR SUITE A104
RANCHO MIRAGE CA
92270-4126
US

IV. Provider business mailing address

72780 COUNTRY CLUB DR SUITE A104
RANCHO MIRAGE CA
92270-4126
US

V. Phone/Fax

Practice location:
  • Phone: 760-837-8020
  • Fax: 760-834-3780
Mailing address:
  • Phone: 760-837-8020
  • Fax: 760-834-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number525368
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number555
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: