Healthcare Provider Details

I. General information

NPI: 1942419544
Provider Name (Legal Business Name): JESSICA BETH LIFSHUTZ-GRINBERG CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 MADRONE ST
WILLITS CA
95490-4249
US

IV. Provider business mailing address

PO BOX 1738
MENDOCINO CA
95460-1738
US

V. Phone/Fax

Practice location:
  • Phone: 707-937-3003
  • Fax: 707-937-6267
Mailing address:
  • Phone: 707-937-6267
  • Fax: 707-937-1967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number1667
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number1667
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: