Healthcare Provider Details

I. General information

NPI: 1457848319
Provider Name (Legal Business Name): CARLOS L GRANDELA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 S ALMA SCHOOL RD STE 131
MESA AZ
85210-3088
US

IV. Provider business mailing address

3241 S MICHIGAN AVE
CHICAGO IL
60616-4201
US

V. Phone/Fax

Practice location:
  • Phone: 480-924-8755
  • Fax: 480-854-1864
Mailing address:
  • Phone: 312-949-7751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011198
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: