Provider Demographics
NPI:1316702053
Name:AVALO GRINAN, LEONARDO JESUS
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:JESUS
Last Name:AVALO GRINAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 N WALNUT RD TRLR 61
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-6430
Mailing Address - Country:US
Mailing Address - Phone:702-210-7967
Mailing Address - Fax:
Practice Address - Street 1:625 N LAMB BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-6355
Practice Address - Country:US
Practice Address - Phone:702-331-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant