Provider Demographics
NPI:1265641088
Name:CARLOS A. GRANDE
Entity Type:Organization
Organization Name:CARLOS A. GRANDE
Other - Org Name:WEST COAST MOBILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:GRANDE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:415-584-2073
Mailing Address - Street 1:69 SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94112-2615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:69 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112-2615
Practice Address - Country:US
Practice Address - Phone:415-584-2073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTN01009F343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01009FOtherMEDI-CAL PROVIDER NUMBER