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NPI Code Detail

MEDICARE: ELIJAH J GRANT

MEDICARE: ELIJAH J GRANT
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
1390200000XStudent in an Organized Health Care Education/Training Program

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
17368OTHERCAMEDI-CAL
27667OTHERCAMEDI-CAL
37708OTHERCAMEDI-CAL
47184OTHERCAMEDI-CAL

General Provider Information

NPI Number : 1710845508
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELIJAH J GRANT
Provider Business Mailing Address
First Line : 205 PASADENA AVE
Second Line :
City : SOUTH PASADENA
State : CA
Zip : 91030-2919
Country : US
Telephone Number : 626-755-7710
Fax Number :
Provider Business Practice Location Address
First Line : 205 PASADENA AVE
Second Line :
City : SOUTH PASADENA
State : CA
Zip : 91030-2919
Country : US
Telephone Number : 626-755-7710
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/12/2026
Last Update Date : 01/12/2026

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