1811264088 NPI number — GATHERING PRECIOUS STONES, LLC

Table of content: (NPI 1811264088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811264088 NPI number — GATHERING PRECIOUS STONES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATHERING PRECIOUS STONES, 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:
1811264088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 PAVILION CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30253-6666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-913-9114
Provider Business Mailing Address Fax Number:
404-813-9114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 PAVILION CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30253-6666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-913-9114
Provider Business Practice Location Address Fax Number:
404-923-9933
Provider Enumeration Date:
11/16/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
DENISE
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
404-913-9114

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 305S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 302R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003149794A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".