Provider Demographics
NPI:1215629571
Name:GRAVES, DREVION
Entity type:Individual
Prefix:
First Name:DREVION
Middle Name:
Last Name:GRAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DRE
Other - Middle Name:
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3488 MANZANITA DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3488 MANZANITA DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3027
Practice Address - Country:US
Practice Address - Phone:909-648-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker