Provider Demographics
NPI:1043874068
Name:HIDEAWAY HEALTH TABLE LLC
Entity Type:Organization
Organization Name:HIDEAWAY HEALTH TABLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLILAND
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:256-426-3593
Mailing Address - Street 1:4817 BROWNSTON CT SE
Mailing Address - Street 2:
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-9161
Mailing Address - Country:US
Mailing Address - Phone:256-426-3593
Mailing Address - Fax:
Practice Address - Street 1:4817 BROWNSTON CT SE
Practice Address - Street 2:
Practice Address - City:OWENS CROSS ROADS
Practice Address - State:AL
Practice Address - Zip Code:35763-9161
Practice Address - Country:US
Practice Address - Phone:256-426-3593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies