Provider Demographics
NPI:1346308764
Name:GRUENLOH, KELLY C (RPT)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:C
Last Name:GRUENLOH
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 HENRIETTA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-2519
Mailing Address - Country:US
Mailing Address - Phone:805-239-3696
Mailing Address - Fax:
Practice Address - Street 1:417 HENRIETTA AVE
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-2519
Practice Address - Country:US
Practice Address - Phone:805-239-3696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30378208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPT001411Medicaid
CAW19392Medicare ID - Type UnspecifiedMEDICARE GROUP