Provider Demographics
NPI:1376028340
Name:GRANBERRY, TRACY RACHAE (RD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:RACHAE
Last Name:GRANBERRY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2084 LA LUNA WAY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2732
Mailing Address - Country:US
Mailing Address - Phone:909-576-3496
Mailing Address - Fax:
Practice Address - Street 1:11801 PIERCE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-4408
Practice Address - Country:US
Practice Address - Phone:951-750-0085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA920321133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered