Healthcare Provider Details

I. General information

NPI: 1104571405
Provider Name (Legal Business Name): GTW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 W PARIS ST
HUNTINGDON TN
38344-3608
US

IV. Provider business mailing address

PO BOX 506
HUNTINGDON TN
38344-0506
US

V. Phone/Fax

Practice location:
  • Phone: 731-535-3600
  • Fax: 731-535-3603
Mailing address:
  • Phone: 731-431-2579
  • Fax: 731-499-8175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LISA KAY PAGE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 731-693-3465