Healthcare Provider Details

I. General information

NPI: 1639452162
Provider Name (Legal Business Name): JASON E. GROMOLL R.D., C.D.N
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 SPRINGDALE WAY
ROTTERDAM NY
12306-5606
US

IV. Provider business mailing address

206 SPRINGDALE WAY
ROTTERDAM NY
12306-5606
US

V. Phone/Fax

Practice location:
  • Phone: 518-250-3898
  • Fax:
Mailing address:
  • Phone: 518-250-3898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number007243
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: