Provider Demographics
NPI:1396346789
Name:EDEN-GRAVES, CHRISTINE (DR)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:EDEN-GRAVES
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2668 ROGUE RIVER CIR
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-4921
Mailing Address - Country:US
Mailing Address - Phone:415-867-7842
Mailing Address - Fax:
Practice Address - Street 1:2540 CARMICHAEL WAY
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-5314
Practice Address - Country:US
Practice Address - Phone:916-482-0465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist