Basic Information
| Provider Information | |||||||||
| NPI: | 1164913968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | TAISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 ADELINE ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947032407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106010203 | ||||||||
| FaxNumber: | 5106014002 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 ADELINE ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947032407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106010203 | ||||||||
| FaxNumber: | 5106014002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2018 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246Y00000X | N | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Health Info | 246Y00000X | CA | Y | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Health Info |
No ID Information.