Provider Demographics
NPI:1376296582
Name:ANTOINE, GUS SR
Entity Type:Individual
Prefix:
First Name:GUS
Middle Name:
Last Name:ANTOINE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 FT CAMPBELL BLVD
Mailing Address - Street 2:SUITE A PMB 1089
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042
Mailing Address - Country:US
Mailing Address - Phone:833-687-8333
Mailing Address - Fax:
Practice Address - Street 1:2033 FT CAMPBELL BLVD
Practice Address - Street 2:SUITE A PMB 1089
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042
Practice Address - Country:US
Practice Address - Phone:833-687-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7094741172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver