1164668059 NPI number — GOS OPERATOR LLC

Table of content: (NPI 1164668059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164668059 NPI number — GOS OPERATOR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOS OPERATOR 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:
1164668059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3151A KNOLLWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36693-2745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-661-7608
Provider Business Mailing Address Fax Number:
251-602-9146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3151A KNOLLWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36693-2745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-661-7608
Provider Business Practice Location Address Fax Number:
251-602-9146
Provider Enumeration Date:
12/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MCAULIFFE
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
251-661-7608

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  5525 (NH) , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X , with the licence number: 5527 (SCALF) , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 47-579905 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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