Provider Demographics
NPI:1659625135
Name:CEFALO, GRANT HYRUM (RD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:HYRUM
Last Name:CEFALO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 N 500 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2400
Mailing Address - Country:US
Mailing Address - Phone:435-452-1844
Mailing Address - Fax:
Practice Address - Street 1:1350 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-452-1844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6045445-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered