Provider Demographics
NPI:1700227246
Name:HARDIGREE, TILLMAN BLAKE (CST)
Entity Type:Individual
Prefix:
First Name:TILLMAN
Middle Name:BLAKE
Last Name:HARDIGREE
Suffix:
Gender:M
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 WARREN WAY
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3855 PLEASANT HILL RD STE 470
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1417
Practice Address - Country:US
Practice Address - Phone:770-813-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA078608246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist