Healthcare Provider Details

I. General information

NPI: 1760983787
Provider Name (Legal Business Name): GSB ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2018
Last Update Date: 02/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 W JOHNSON ST
RALEIGH NC
27603-1259
US

IV. Provider business mailing address

2033 SHINGLEBACK DR
WAKE FOREST NC
27587-6554
US

V. Phone/Fax

Practice location:
  • Phone: 919-940-1785
  • Fax:
Mailing address:
  • Phone: 919-940-1785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number6570
License Number StateNC

VIII. Authorized Official

Name: MR. WILLIAM GRAHAM
Title or Position: OWNER/OPERATOR
Credential: HAIR LOSS SPECIALIST
Phone: 919-940-1785