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NPI Code Detail

MEDICARE: JUAN GRULLON

MEDICARE: JUAN GRULLON
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
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1104320357
Entity Type Code : Individual
Provider Name (Legal Business Name) : JUAN GRULLON
Provider Business Mailing Address
First Line : 302 EUSTIS ST
Second Line :
City : ROXBURY
State : MA
Zip : 02119-3800
Country : US
Telephone Number : 617-445-1123
Fax Number :
Provider Business Practice Location Address
First Line : 302 EUSTIS ST
Second Line :
City : ROXBURY
State : MA
Zip : 02119-3800
Country : US
Telephone Number : 617-445-1123
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/22/2018
Last Update Date : 03/22/2018

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Directions to “ JUAN GRULLON ” Practice Location

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