Provider Demographics
NPI:1841836426
Name:GRANADOS, GORGE CARLO VIZCARRA
Entity type:Individual
Prefix:
First Name:GORGE CARLO
Middle Name:VIZCARRA
Last Name:GRANADOS
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 1:3568 WHITE WOLF CT
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-0659
Mailing Address - Country:US
Mailing Address - Phone:559-352-6479
Mailing Address - Fax:
Practice Address - Street 1:3360 N HIGHWAY 59 STE K
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-9405
Practice Address - Country:US
Practice Address - Phone:209-726-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator