Provider Demographics
NPI:1902569148
Name:GRIGGS, RONALD EUGENE
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:EUGENE
Last Name:GRIGGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1821
Mailing Address - Country:US
Mailing Address - Phone:323-751-3026
Mailing Address - Fax:
Practice Address - Street 1:3850 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-1821
Practice Address - Country:US
Practice Address - Phone:323-751-3026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X, 390200000X
CAMPSS-ZLYGHR175T00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No172V00000XOther Service ProvidersCommunity Health Worker