=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629734520
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | G & M HEALTHCARE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2021
-----------------------------------------------------
Last Update Date | 12/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 N BEECH ST STE 3
-----------------------------------------------------
City | TALLULAH
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71282-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-493-5120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 805 N BEECH ST STE 3
-----------------------------------------------------
City | TALLULAH
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71282-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LATONYA THOMAS
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 314-493-5120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------