Provider Demographics
NPI:1376950865
Name:GATSON SERVICE PROVIDER
Entity Type:Organization
Organization Name:GATSON SERVICE PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PASTOR
Authorized Official - Prefix:
Authorized Official - First Name:OPHELIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-398-1204
Mailing Address - Street 1:2902 NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23222-3541
Mailing Address - Country:US
Mailing Address - Phone:804-398-1204
Mailing Address - Fax:
Practice Address - Street 1:2902 NOBLE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23222-3541
Practice Address - Country:US
Practice Address - Phone:804-398-1204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization