Provider Demographics
NPI:1760175434
Name:GROVOM, SABRINA ELLY (RD)
Entity Type:Individual
Prefix:
First Name:SABRINA
Middle Name:ELLY
Last Name:GROVOM
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 1:2329 MOONLIGHT GLN
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-3845
Mailing Address - Country:US
Mailing Address - Phone:760-975-5859
Mailing Address - Fax:
Practice Address - Street 1:2329 MOONLIGHT GLN
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-3845
Practice Address - Country:US
Practice Address - Phone:760-975-5859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA86292044133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered