Provider Demographics
NPI:1780396721
Name:TESTER, GRADY DOUGLAS
Entity type:Individual
Prefix:
First Name:GRADY
Middle Name:DOUGLAS
Last Name:TESTER
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:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:PAISLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32767-0465
Mailing Address - Country:US
Mailing Address - Phone:352-250-4974
Mailing Address - Fax:
Practice Address - Street 1:1312 OLD MOUNT DORA RD
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-7946
Practice Address - Country:US
Practice Address - Phone:352-250-4974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide