Organization
GRANO DE ORO FAMILY MENTAL HEALTH SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RODOLFO FIDENCIO GRANO PH.D. (CLINICAL PSYCHOLOGIST)
(505) 617-6313
Entity
Organization
Contact information
Practice address
1920 7TH ST, LAS VEGAS, NM 87701-4956
(505) 617-6313
Mailing address
PO BOX 1856, LAS VEGAS, NM 87701-1856
(505) 617-6313
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
0811
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1356452981
NPI
NM
05
—
17480221
—
NM
01
—
NM301219
MEDICARE
—
Enumeration date
04/15/2010
Last updated
04/15/2010
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