Provider Demographics
NPI:1407320492
Name:MCGRUDER, TEONDRA SHANTAY
Entity Type:Individual
Prefix:
First Name:TEONDRA
Middle Name:SHANTAY
Last Name:MCGRUDER
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 1:1032 LAKEVIEW ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30434-5963
Mailing Address - Country:US
Mailing Address - Phone:478-206-2864
Mailing Address - Fax:
Practice Address - Street 1:1032 LAKEVIEW ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:GA
Practice Address - Zip Code:30434-5963
Practice Address - Country:US
Practice Address - Phone:478-206-2864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1314571744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management