MEDICARE: MR. GEROME ALONZO GRIVAS NP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	17743	CA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	12129	TN

General Provider Information

NPI Number	:	1497883607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GEROME ALONZO GRIVAS NP

Provider Business Mailing Address
First Line	:	1118 CONTINENTALS WAY
Second Line	:
City	:	BELMONT
State	:	CA
Zip	:	94002-3119
Country	:	US
Telephone Number	:	650-270-5393
Fax Number	:

Provider Business Practice Location Address
First Line	:	3175 LENOX PARK BLVD STE 412
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38115-4256
Country	:	US
Telephone Number	:	901-273-2369
Fax Number	:

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	12/30/2021

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