Healthcare Provider Details

I. General information

NPI: 1427762376
Provider Name (Legal Business Name): CHARLES PETER GRANDELLI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. CHARLES P GRANDELLI

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 CONTRA COSTA ST STE D
SAND CITY CA
93955-3056
US

IV. Provider business mailing address

11773 FRANCIS DR
GRASS VALLEY CA
95949-6681
US

V. Phone/Fax

Practice location:
  • Phone: 831-886-0475
  • Fax: 831-855-0157
Mailing address:
  • Phone: 831-886-0475
  • Fax: 831-855-0157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number274700004
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: