Provider Demographics
NPI:1104571405
Name:GTW, LLC
Entity type:Organization
Organization Name:GTW, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-693-3465
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-0506
Mailing Address - Country:US
Mailing Address - Phone:731-431-2579
Mailing Address - Fax:731-499-8175
Practice Address - Street 1:126 W PARIS ST
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:TN
Practice Address - Zip Code:38344-3608
Practice Address - Country:US
Practice Address - Phone:731-535-3600
Practice Address - Fax:731-535-3603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ071950Medicaid