Healthcare Provider Details

I. General information

NPI: 1881509503
Provider Name (Legal Business Name): JOSE GRAJO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

1134 W TANAGER AVE
HAYDEN ID
83835-8843
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-4000
  • Fax:
Mailing address:
  • Phone: 609-605-3181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT-2874
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: