Organization
GRANO DE ORO FAMILY MENTAL HEALTH SERVICES
Active
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
Update your record
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