Healthcare Provider Details

I. General information

NPI: 1851684336
Provider Name (Legal Business Name): JEFFREY NATHAN GRANT,M.D. A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8733 BEVERLY BLVD
WEST HOLLYWOOD CA
90048-1827
US

IV. Provider business mailing address

8733 BEVERLY BLVD
WEST HOLLYWOOD CA
90048-1827
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-4511
  • Fax: 310-659-1520
Mailing address:
  • Phone: 310-659-4511
  • Fax: 310-659-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA24260
License Number StateCA

VIII. Authorized Official

Name: DR. JEFFREY JNATHAN GRANT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-659-4511