Provider Demographics
NPI:1942697115
Name:GRISAFFI, CHRIS M (BS)
Entity Type:Individual
Prefix:MR
First Name:CHRIS
Middle Name:M
Last Name:GRISAFFI
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N ORCHARD ST STE 8
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2255
Mailing Address - Country:US
Mailing Address - Phone:208-331-4097
Mailing Address - Fax:208-331-4095
Practice Address - Street 1:1010 N ORCHARD ST STE 8
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2255
Practice Address - Country:US
Practice Address - Phone:208-331-4097
Practice Address - Fax:208-331-4095
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP1869246QL0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1295917375Medicaid