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General NPI Number Information
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NPI Number | 1295978328
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Entity Type | Organization
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Legal Business Name | GHOLSTON TRUST LLC
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Dates
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Enumeration Date | 04/20/2009
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Last Update Date | 04/22/2009
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Provider Practice Location Address
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Address Line | 773 CLIFFORD AVE
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City | ARDMORE
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State | PA
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Zip | 19003-2027
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Country | US
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Telephone | 215-594-9492
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Fax | 215-594-9492
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Provider Business Mailing Address
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Address Line | 773 CLIFFORD AVE
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City | ARDMORE
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State | PA
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Zip | 19003-2027
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | FOUNDER / CEO
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Name | MR. JARRAD MARCELLAS GHOLSTON SR.
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Credential |
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Telephone | 215-594-9492
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State | PA
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