Healthcare Provider Details

I. General information

NPI: 1265628390
Provider Name (Legal Business Name): CRAIG SAEWONG RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MDG/SGQD 101 BODIN CIR
TRAVIS AFB CA
94535-1800
US

IV. Provider business mailing address

DAVID GRANT MEDICAL CENTER 101 BODIN CIR
FAIRFIELD CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7867
  • Fax:
Mailing address:
  • Phone: 707-423-3367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number929514
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: