Healthcare Provider Details

I. General information

NPI: 1215532866
Provider Name (Legal Business Name): GATHERING PLACE OF LICKING COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 GAINOR AVE
NEWARK OH
43055-4817
US

IV. Provider business mailing address

35 GAINOR AVE
NEWARK OH
43055-4817
US

V. Phone/Fax

Practice location:
  • Phone: 740-975-3372
  • Fax:
Mailing address:
  • Phone: 740-975-3372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALYSSA SUE GOLDEN
Title or Position: OWNER
Credential:
Phone: 740-975-3372