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General NPI Number Information
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NPI Number | 1457848319
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Entity Type | Individual
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Provider Name | CARLOS L GRANDELA OD
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Gender | Male
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Dates
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Enumeration Date | 04/17/2018
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Last Update Date | 01/10/2024
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Provider Practice Location Address
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Address Line | 1830 S ALMA SCHOOL RD STE 131
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City | MESA
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State | AZ
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Zip | 85210-3088
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Country | US
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Telephone | 480-924-8755
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Fax | 480-854-1864
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Provider Business Mailing Address
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Address Line | 3241 S MICHIGAN AVE
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City | CHICAGO
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State | IL
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Zip | 60616-4201
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Country | US
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Telephone | 312-949-7751
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046011198
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License Number State | IL
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