Healthcare Provider Details

I. General information

NPI: 1750515342
Provider Name (Legal Business Name): MEREDITH ROSE GRANHOLM IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 HOSPITAL LOOP 92 AMDS/SGPE
FAIRCHILD AFB WA
99011-8704
US

IV. Provider business mailing address

701 HOSPITAL LOOP 92 AMDS/SGPE
FAIRCHILD AFB WA
99011-8704
US

V. Phone/Fax

Practice location:
  • Phone: 509-247-5755
  • Fax: 507-247-8833
Mailing address:
  • Phone: 509-247-5755
  • Fax: 507-247-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: