Provider Demographics
NPI:1326557026
Name:GRAJEDA, RUBEN (BA)
Entity Type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:
Last Name:GRAJEDA
Suffix:
Gender:M
Credentials:BA
Other - Prefix:MR
Other - First Name:RUBEN
Other - Middle Name:
Other - Last Name:GRAJEDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RUBEN GRAJEDA
Mailing Address - Street 1:3561 N F ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-2120
Mailing Address - Country:US
Mailing Address - Phone:562-306-2958
Mailing Address - Fax:
Practice Address - Street 1:3561 N F ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-2120
Practice Address - Country:US
Practice Address - Phone:562-306-2958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XMedicaid