=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942129473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIRLYGASTRO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2026
-----------------------------------------------------
Last Update Date | 07/10/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 EMERSON ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-6108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-240-5192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1424 BELMONTE AVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-8505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-240-5192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IMONI DENISE KEITT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-240-5192
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174200000X
-----------------------------------------------------
Taxonomy Name | Meals Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------