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General NPI Number Information
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NPI Number | 1023334083
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Entity Type | Organization
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Legal Business Name | GRANO DE ORO FAMILY MENTAL HEALTH SERVICES
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Dates
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Enumeration Date | 04/15/2010
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Last Update Date | 04/15/2010
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Provider Practice Location Address
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Address Line | 1920 7TH ST
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City | LAS VEGAS
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State | NM
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Zip | 87701-4956
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Country | US
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Telephone | 505-617-6313
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1856
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City | LAS VEGAS
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State | NM
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Zip | 87701-1856
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Country | US
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Telephone | 505-617-6313
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. RODOLFO FIDENCIO GRANO
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Credential | PH.D.
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Telephone | 505-617-6313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0811
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License Number State | NM
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