Provider Demographics
NPI:1871738914
Name:CARLOS L GRANDELA O.D. PLC
Entity type:Organization
Organization Name:CARLOS L GRANDELA O.D. PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRANDELA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:480-924-8755
Mailing Address - Street 1:1830 S ALMA SCHOOL RD STE 131
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3088
Mailing Address - Country:US
Mailing Address - Phone:480-924-8755
Mailing Address - Fax:480-854-1864
Practice Address - Street 1:1830 S ALMA SCHOOL RD STE 131
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3088
Practice Address - Country:US
Practice Address - Phone:480-695-2595
Practice Address - Fax:480-705-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1378152WL0500X
AZ560152WL0500X
AZ526152WL0500X
AZ542152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ132727Medicare PIN
AZZ104729Medicare PIN
AZZ132730Medicare PIN
AZZ131731Medicare PIN