Healthcare Provider Details

I. General information

NPI: 1932899630
Provider Name (Legal Business Name): GLL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 HWY 40 E STE M237
KINGSLAND GA
31548-6500
US

IV. Provider business mailing address

PO BOX 739472
DALLAS TX
75373-9472
US

V. Phone/Fax

Practice location:
  • Phone: 904-874-9709
  • Fax:
Mailing address:
  • Phone: 904-874-9709
  • Fax: 904-650-2911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: STACY ASHLEY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 904-874-9709