Provider Demographics
NPI:1467960062
Name:GRASSO, JEFFREY SALVATORE
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SALVATORE
Last Name:GRASSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TORE
Other - Middle Name:
Other - Last Name:GRASSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:773 WIGAN PIER DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-6584
Mailing Address - Country:US
Mailing Address - Phone:702-419-1925
Mailing Address - Fax:
Practice Address - Street 1:1903 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1260
Practice Address - Country:US
Practice Address - Phone:702-968-9372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV172V00000XMedicaid