Healthcare Provider Details

I. General information

NPI: 1477991735
Provider Name (Legal Business Name): GRANADA 1 CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6712 YELLOWSTONE BLVD APT A19
FOREST HILLS NY
11375-2329
US

IV. Provider business mailing address

6712 YELLOWSTONE BLVD APT A19
FOREST HILLS NY
11375-2329
US

V. Phone/Fax

Practice location:
  • Phone: 917-676-5878
  • Fax:
Mailing address:
  • Phone: 917-676-5878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. CARLOS DANIEL AVENDANO
Title or Position: SPECIAL EDUCATION SERVICE PROVIDER
Credential:
Phone: 917-676-5878