Provider Demographics
NPI:1730904905
Name:GRAJEDA, GENARO
Entity type:Individual
Prefix:
First Name:GENARO
Middle Name:
Last Name:GRAJEDA
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 1:1013 SUNBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-5357
Mailing Address - Country:US
Mailing Address - Phone:951-805-6580
Mailing Address - Fax:
Practice Address - Street 1:5250 UNIVERSITY PKWY STE A
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-7047
Practice Address - Country:US
Practice Address - Phone:951-805-6580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker