Basic Information
| Provider Information | |||||||||
| NPI: | 1407233372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRENADE | ||||||||
| FirstName: | TORI | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 WATSON BLVD | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310933431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789224281 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 GROVE RD | ||||||||
| Address2: | ATT: RESIDENCY COORDINDATOR | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296055611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644557844 | ||||||||
| FaxNumber: | 8644557848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2015 | ||||||||
| LastUpdateDate: | 09/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 83844 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 83844 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.