Provider Demographics
NPI:1245222942
Name:CARLO, GRISELLE E (MS, MT)
Entity Type:Individual
Prefix:MRS
First Name:GRISELLE
Middle Name:E
Last Name:CARLO
Suffix:
Gender:F
Credentials:MS, MT
Other - Prefix:MRS
Other - First Name:GRISELLE
Other - Middle Name:E
Other - Last Name:CARLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, MT
Mailing Address - Street 1:24 CALLE DR BASORA N
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-4831
Mailing Address - Country:US
Mailing Address - Phone:787-833-4065
Mailing Address - Fax:787-805-6605
Practice Address - Street 1:24 CALLE DR BASORA N
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4831
Practice Address - Country:US
Practice Address - Phone:787-833-4065
Practice Address - Fax:787-805-6605
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2011-04-01
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-18
Provider Licenses
StateLicense IDTaxonomies
PR3755246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR30258Medicare ID - Type UnspecifiedPROVIDER NUMBER