Provider Demographics
NPI:1376084814
Name:HEALTHWISE 360 LLC
Entity Type:Organization
Organization Name:HEALTHWISE 360 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTGSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-736-4300
Mailing Address - Street 1:617 BOLEN AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-1521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 STONEBRIDGE BLVD STE M
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2178
Practice Address - Country:US
Practice Address - Phone:731-267-2836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ027339Medicaid