Provider Demographics
NPI:1184215998
Name:GRADDICK, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GRADDICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 PERRY LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL
Mailing Address - State:SC
Mailing Address - Zip Code:29630-9403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 PERRY LN
Practice Address - Street 2:
Practice Address - City:CENTRAL
Practice Address - State:SC
Practice Address - Zip Code:29630-9403
Practice Address - Country:US
Practice Address - Phone:864-508-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy