Provider Demographics
NPI:1730678756
Name:GRANDTAG MADISONREALTY LLC
Entity Type:Organization
Organization Name:GRANDTAG MADISONREALTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FORBES
Authorized Official - Middle Name:WILLARD
Authorized Official - Last Name:BURDETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-796-8700
Mailing Address - Street 1:3452 E FOOTHILL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3158
Mailing Address - Country:US
Mailing Address - Phone:626-796-8700
Mailing Address - Fax:
Practice Address - Street 1:501 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-5527
Practice Address - Country:US
Practice Address - Phone:909-686-0117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty