Healthcare Provider Details

I. General information

NPI: 1780396721
Provider Name (Legal Business Name): GRADY DOUGLAS TESTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 OLD MOUNT DORA RD
EUSTIS FL
32726-7946
US

IV. Provider business mailing address

PO BOX 465
PAISLEY FL
32767-0465
US

V. Phone/Fax

Practice location:
  • Phone: 352-250-4974
  • Fax:
Mailing address:
  • Phone: 352-250-4974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: