Provider Demographics
NPI:1467859892
Name:GRONDA, TED
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:GRONDA
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 1:8180 MANCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1866
Mailing Address - Country:US
Mailing Address - Phone:734-775-9136
Mailing Address - Fax:
Practice Address - Street 1:8180 MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-1866
Practice Address - Country:US
Practice Address - Phone:734-775-9136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704308135163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse