Healthcare Provider Details

I. General information

NPI: 1669514089
Provider Name (Legal Business Name): SHERWOOD O GRIGGS SR. CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2963 LEXINGTON TRACE DR SE
SMYRNA GA
30080-3784
US

IV. Provider business mailing address

2963 LEXINGTON TRACE DR SE
SMYRNA GA
30080-3784
US

V. Phone/Fax

Practice location:
  • Phone: 706-351-1612
  • Fax:
Mailing address:
  • Phone: 706-351-1612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number2894
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: