Basic Information
| Provider Information | |||||||||
| NPI: | 1992424915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANADOS | ||||||||
| FirstName: | KARLA | ||||||||
| MiddleName: | YADIRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1709 MOON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871123935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052710329 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1709 MOON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871123935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052710329 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2022 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 65224086 | 05 | NM | MEDICAID |