1003126574 NPI number — GSW CLINIC, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003126574 NPI number — GSW CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GSW CLINIC, 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:
6
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:
1003126574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 47125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32247-7125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-477-4480
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3728 PHILLIPS HWY
Provider Second Line Business Practice Location Address:
SUITE 13
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-9300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-477-4480
Provider Business Practice Location Address Fax Number:
904-683-5619
Provider Enumeration Date:
10/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WEBB
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
PRIMARY MEMBER
Authorized Official Telephone Number:
904-477-4480

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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