Provider Demographics
NPI:1659861086
Name:GRUPE, MOLLY (RD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:GRUPE
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 1:882 N MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-4625
Mailing Address - Country:US
Mailing Address - Phone:310-351-0777
Mailing Address - Fax:
Practice Address - Street 1:825 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3424
Practice Address - Country:US
Practice Address - Phone:626-471-9710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1255795977Medicaid