Healthcare Provider Details

I. General information

NPI: 1275909111
Provider Name (Legal Business Name): PAULINE GRISSOM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE 6M31
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

126 MOUNTAIN SPRING AVE
SAN FRANCISCO CA
94114-2120
US

V. Phone/Fax

Practice location:
  • Phone: 415-206-5220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1065352
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: