Healthcare Provider Details

I. General information

NPI: 1114834751
Provider Name (Legal Business Name): TEMPETTS BRUNDIDGE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 N LEWIS ST
LAGRANGE GA
30240-2740
US

IV. Provider business mailing address

316 N LEWIS ST
LAGRANGE GA
30240-2740
US

V. Phone/Fax

Practice location:
  • Phone: 813-438-6796
  • Fax: 706-705-9791
Mailing address:
  • Phone: 813-438-6796
  • Fax: 706-705-9791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: