Provider Demographics
NPI:1427762376
Name:GRANDELLI, CHARLES PETER
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:PETER
Last Name:GRANDELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:CHARLES
Other - Middle Name:P
Other - Last Name:GRANDELLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11773 FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-6681
Mailing Address - Country:US
Mailing Address - Phone:831-886-0475
Mailing Address - Fax:831-855-0157
Practice Address - Street 1:1815 CONTRA COSTA ST STE D
Practice Address - Street 2:
Practice Address - City:SAND CITY
Practice Address - State:CA
Practice Address - Zip Code:93955-3056
Practice Address - Country:US
Practice Address - Phone:831-886-0475
Practice Address - Fax:831-855-0157
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA274700004374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide