Individual
MISS TIERRA ILICIA LEIGH GRUBBS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
ABOC, FNAO
Contact information
Practice address
575 ANTON BLVD FL 3, COSTA MESA, CA 92626-7169
(562) 313-5202
Mailing address
575 ANTON BLVD FL 3, COSTA MESA, CA 92626-7169
(562) 313-5202
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
D70604
CA
156FX1800X
Optician
Primary
SL40306
CA
Other
Enumeration date
01/18/2016
Last updated
01/18/2016
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