Healthcare Provider Details

I. General information

NPI: 1942129473
Provider Name (Legal Business Name): GIRLYGASTRO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 EMERSON ST
JACKSONVILLE FL
32207-6108
US

IV. Provider business mailing address

1424 BELMONTE AVE
JACKSONVILLE FL
32207-8505
US

V. Phone/Fax

Practice location:
  • Phone: 386-240-5192
  • Fax:
Mailing address:
  • Phone: 386-240-5192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State

VIII. Authorized Official

Name: IMONI DENISE KEITT
Title or Position: OWNER
Credential:
Phone: 386-240-5192