Provider Demographics
NPI:1821070863
Name:GRAPEVINE, AMBER (MS, RD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:GRAPEVINE
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 E RAMSEY RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4636
Mailing Address - Country:US
Mailing Address - Phone:210-349-9300
Mailing Address - Fax:210-366-2558
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:SUITE GL 70
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5609
Practice Address - Country:US
Practice Address - Phone:210-226-9705
Practice Address - Fax:210-223-4555
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06583133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT06583OtherLICENSE NUMBER