MEDICARE: MS. CANDACE M GRANADOS P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	468	NM

General Provider Information

NPI Number	:	1437128444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CANDACE M GRANADOS P.T.

Provider Business Mailing Address
First Line	:	525 DANDELION LN
Second Line	:
City	:	CORRALES
State	:	NM
Zip	:	87048-7821
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4824 MCMAHON BLVD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-5412
Country	:	US
Telephone Number	:	505-897-3575
Fax Number	:	505-897-3726

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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