Provider Demographics
NPI:1588288260
Name:GNV CHIRO PLLC
Entity type:Organization
Organization Name:GNV CHIRO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-949-0843
Mailing Address - Street 1:5745 SW 75TH ST NUM 275
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-5504
Mailing Address - Country:US
Mailing Address - Phone:352-949-0843
Mailing Address - Fax:
Practice Address - Street 1:5745 SW 75TH ST NUM 275
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-5504
Practice Address - Country:US
Practice Address - Phone:352-949-0843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GNV CHIRO PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-29
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104032700Medicaid