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General NPI Number Information
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NPI Number | 1437622701
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Entity Type | Organization
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Legal Business Name | GSG PRIDE HEALTHCARE LLC
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Dates
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Enumeration Date | 01/09/2019
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Last Update Date | 01/30/2020
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Provider Practice Location Address
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Address Line | 8391 S SHADY TRAIL DR
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City | PENDLETON
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State | IN
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Zip | 46064-8652
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Country | US
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Telephone | 317-507-2395
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Fax |
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Provider Business Mailing Address
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Address Line | 8391 S SHADY TRAIL DR
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City | PENDLETON
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State | IN
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Zip | 46064-8652
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Country | US
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Telephone | 317-743-0009
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER/OWNER
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Name | TARIS D GONZALEZ
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Credential | NP
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Telephone | 317-743-0009
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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