Provider Demographics
NPI:1164889424
Name:GRUBBS, TIERRA ILICIA LEIGH (ABOC, FNAO)
Entity Type:Individual
Prefix:MISS
First Name:TIERRA
Middle Name:ILICIA LEIGH
Last Name:GRUBBS
Suffix:
Gender:F
Credentials:ABOC, FNAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 ANTON BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-7169
Mailing Address - Country:US
Mailing Address - Phone:562-313-5202
Mailing Address - Fax:
Practice Address - Street 1:575 ANTON BLVD FL 3
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7169
Practice Address - Country:US
Practice Address - Phone:562-313-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD70604156FX1800X
CASL40306156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician