Healthcare Provider Details

I. General information

NPI: 1588240782
Provider Name (Legal Business Name): GTG ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 RICHLAND WEST CIR STE C
WACO TX
76712-7911
US

IV. Provider business mailing address

PO BOX 23421
WACO TX
76702-3421
US

V. Phone/Fax

Practice location:
  • Phone: 254-776-8008
  • Fax: 547-766-8922
Mailing address:
  • Phone: 547-768-0082
  • Fax: 254-776-6892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA KIRK
Title or Position: PRESIDENT
Credential: DO
Phone: 547-768-0082