Provider Demographics
NPI:1356664171
Name:GRISARD, RICHARD HENRY (OTR/L;CO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HENRY
Last Name:GRISARD
Suffix:
Gender:M
Credentials:OTR/L;CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FAIRFAX RD AT VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-4399
Mailing Address - Country:US
Mailing Address - Phone:801-536-3820
Mailing Address - Fax:
Practice Address - Street 1:FAIRFAX RD AT VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-4399
Practice Address - Country:US
Practice Address - Phone:801-536-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
UT106808-4201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist