Provider Demographics
NPI:1962823872
Name:VELASCO, GRENDALE (DPT)
Entity Type:Individual
Prefix:
First Name:GRENDALE
Middle Name:
Last Name:VELASCO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4616 W SAHARA AVE
Mailing Address - Street 2:#337
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-3654
Mailing Address - Country:US
Mailing Address - Phone:702-880-4193
Mailing Address - Fax:702-880-4197
Practice Address - Street 1:3835 S JONES BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-7125
Practice Address - Country:US
Practice Address - Phone:702-880-4193
Practice Address - Fax:702-880-4197
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist