Healthcare Provider Details

I. General information

NPI: 1417103276
Provider Name (Legal Business Name): GWIM ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N CRAWFORD ST
TOMPKINSVILLE KY
42167-1617
US

IV. Provider business mailing address

PO BOX 952
TOMPKINSVILLE KY
42167-0952
US

V. Phone/Fax

Practice location:
  • Phone: 270-634-2089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROCKIE MCDANIEL
Title or Position: PRESIDENT
Credential:
Phone: 270-403-5211