Basic Information
| Provider Information | |||||||||
| NPI: | 1821070863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAPEVINE | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 E RAMSEY RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782164636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103499300 | ||||||||
| FaxNumber: | 2103662558 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 MCCULLOUGH AVE | ||||||||
| Address2: | SUITE GL 70 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782125609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102269705 | ||||||||
| FaxNumber: | 2102234555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT06583 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | DT06583 | 01 | TX | LICENSE NUMBER | OTHER |