Provider Demographics
NPI:1821276130
Name:GRENTZ, LIESEL C (DO)
Entity Type:Individual
Prefix:
First Name:LIESEL
Middle Name:C
Last Name:GRENTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 DOWELL RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-4278
Mailing Address - Country:US
Mailing Address - Phone:270-866-2440
Mailing Address - Fax:270-866-2442
Practice Address - Street 1:124 DOWELL RD
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-4278
Practice Address - Country:US
Practice Address - Phone:270-866-2440
Practice Address - Fax:270-866-2442
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100046590Medicaid