Provider Demographics
NPI:1336469774
Name:GRANGROTH, CINDY
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:
Last Name:GRANGROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5244 25TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:MN
Mailing Address - Zip Code:55390-5025
Mailing Address - Country:US
Mailing Address - Phone:763-658-7026
Mailing Address - Fax:
Practice Address - Street 1:5244 25TH ST SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:MN
Practice Address - Zip Code:55390-5025
Practice Address - Country:US
Practice Address - Phone:763-658-7026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1016003-3-AFC385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care