Provider Demographics
NPI:1669883641
Name:GRUNDY, FREDRICK
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:
Last Name:GRUNDY
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 1:6024 N LAGUNA DR
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-7339
Mailing Address - Country:US
Mailing Address - Phone:602-465-9247
Mailing Address - Fax:
Practice Address - Street 1:6024 N LAGUNA DR
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-7339
Practice Address - Country:US
Practice Address - Phone:602-465-9247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education