Provider Demographics
NPI:1083308175
Name:GRANT, MADELAINE (LDO)
Entity Type:Individual
Prefix:
First Name:MADELAINE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 AVENIDA DE LANDA
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-3243
Mailing Address - Country:US
Mailing Address - Phone:775-240-2060
Mailing Address - Fax:
Practice Address - Street 1:5260 W 7TH ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-2332
Practice Address - Country:US
Practice Address - Phone:775-624-2085
Practice Address - Fax:775-624-2087
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV567156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician