Healthcare Provider Details

I. General information

NPI: 1639693906
Provider Name (Legal Business Name): JODI LYNN GRANT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 07/21/2022
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31300 RANCHO COMMUNITY WAY
TEMECULA CA
92592-2805
US

IV. Provider business mailing address

31300 RANCHO COMMUNITY WAY
TEMECULA CA
92592-2805
US

V. Phone/Fax

Practice location:
  • Phone: 951-326-9440
  • Fax:
Mailing address:
  • Phone: 951-326-9440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number890219099
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: