Provider Demographics
NPI:1992971147
Name:GRANJA, FREDDY VINICIO
Entity type:Individual
Prefix:
First Name:FREDDY
Middle Name:VINICIO
Last Name:GRANJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 E LA PALMA AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-1636
Mailing Address - Country:US
Mailing Address - Phone:714-399-1860
Mailing Address - Fax:714-399-1867
Practice Address - Street 1:1900 E LA PALMA AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805
Practice Address - Country:US
Practice Address - Phone:714-399-1860
Practice Address - Fax:714-399-1867
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator