Healthcare Provider Details

I. General information

NPI: 1083699763
Provider Name (Legal Business Name): ELAINE TIZZ GROSSMAN M.S., R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STURGIS STREET BLDG. 1145 BOX 788250
TWENTYNINE PALMS CA
92278-8250
US

IV. Provider business mailing address

STURGIS STREET BLDG. 1145 BOX 788250
TWENTYNINE PALMS CA
92278-8250
US

V. Phone/Fax

Practice location:
  • Phone: 760-830-2120
  • Fax:
Mailing address:
  • Phone: 760-830-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: