MEDICARE: KHRISTIAN ASHLEY GRISWOLD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1033492004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHRISTIAN ASHLEY GRISWOLD

Provider Business Mailing Address
First Line	:	7641 LANI DAWN ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-1605
Country	:	US
Telephone Number	:	702-609-1705
Fax Number	:

Provider Business Practice Location Address
First Line	:	7641 LANI DAWN ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-1605
Country	:	US
Telephone Number	:	702-609-1705
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2011
Last Update Date	:	09/26/2011

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