Provider Demographics
NPI:1134567530
Name:CHAIT LLAMAS, LWBBA GRISSELL (MD)
Entity type:Individual
Prefix:
First Name:LWBBA
Middle Name:GRISSELL
Last Name:CHAIT LLAMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:751 W LEGION RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7732
Practice Address - Country:US
Practice Address - Phone:760-351-4100
Practice Address - Fax:760-351-4101
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA138938208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB272418Medicare PIN