Provider Demographics
NPI:1679943856
Name:GRIMALDOS, JOSE (ND)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:GRIMALDOS
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 BERGENLINE AVE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-7900
Mailing Address - Country:US
Mailing Address - Phone:201-330-8969
Mailing Address - Fax:
Practice Address - Street 1:3600 BERGENLINE AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-7900
Practice Address - Country:US
Practice Address - Phone:201-330-8969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJND100138133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist