Healthcare Provider Details

I. General information

NPI: 1184025298
Provider Name (Legal Business Name): GOGETEMGIRL ENTERTAINMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1723 SHADY LANE RD
COLUMBUS OH
43227-2576
US

IV. Provider business mailing address

1723 SHADY LANE RD
COLUMBUS OH
43227-2576
US

V. Phone/Fax

Practice location:
  • Phone: 614-260-5444
  • Fax:
Mailing address:
  • Phone: 614-260-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number401224260411
License Number StateOH

VIII. Authorized Official

Name: MICHELLE MCDONALD
Title or Position: INDEPENDENT MEDICAID PROVIDER
Credential: STNA
Phone: 614-260-5444