1013680388 NPI number — GIBRALTAR BIZ, LLC

Table of content: (NPI 1013680388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013680388 NPI number — GIBRALTAR BIZ, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GIBRALTAR BIZ, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013680388
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5505 E MOUNTAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30083-3027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-485-3308
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5505 E MOUNTAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONE MOUNTAIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30083-3027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-485-3308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2021

Additional Information

Authorized Official

Authorized Official Last Name:
DINWIDDIE
Authorized Official First Name:
FRITHA
Authorized Official Middle Name:
SKINNER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-485-3308

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: D1103 . This is a "STATE BOARD OF LICENSURE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: DT85347 . This is a "STATE BOARD OF LICENSURE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: ND9557 . This is a "STATE BOARD OF LICENSURE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 677280 . This is a "COMMISSION ON DIETETIC REGISTRATION, ACADEMY OF NUTRITION AND DIETETICS" identifier . This identifiers is of the category "OTHER".
  • Identifier: L003247 . This is a "STATE BOARD OF LICENSURE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1093126997 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 893 . This is a "STATE BOARD OF LICENSURE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 2273 . This is a "STATE BOARD OF LICENSURE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 878 . This is a "STATE BOARD OF LICENSURE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: LDN2393 . This is a "STATE BOARD OF LICENSURE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com