Provider Demographics
NPI:1275143141
Name:GRANDE, FRANCISCO ROBERTO (PTA)
Entity type:Individual
Prefix:
First Name:FRANCISCO
Middle Name:ROBERTO
Last Name:GRANDE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 E AVENUE J9
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4181
Mailing Address - Country:US
Mailing Address - Phone:313-543-6164
Mailing Address - Fax:
Practice Address - Street 1:5930 ADOBE RD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2356
Practice Address - Country:US
Practice Address - Phone:760-367-1743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA50629261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy