Provider Demographics
NPI:1275295578
Name:GRIJALVA, SANTIEGO ANTONIO
Entity Type:Individual
Prefix:MR
First Name:SANTIEGO
Middle Name:ANTONIO
Last Name:GRIJALVA
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 1:28328 INSPIRATION LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIRCLE DR
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-719-3712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN624388163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management