Provider Demographics
NPI:1508409772
Name:GRILE, MATTHEW LORAN
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LORAN
Last Name:GRILE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3538 DEL REY ST APT 9
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5722
Mailing Address - Country:US
Mailing Address - Phone:321-604-5233
Mailing Address - Fax:
Practice Address - Street 1:1325 PACIFIC HWY UNIT 3501
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2600
Practice Address - Country:US
Practice Address - Phone:858-945-6410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG640-552-79-308-0OtherDRIVER LICENSE