Provider Demographics
NPI:1437622701
Name:GSG PRIDE HEALTHCARE LLC
Entity Type:Organization
Organization Name:GSG PRIDE HEALTHCARE LLC
Other - Org Name:MEDICAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:317-743-0009
Mailing Address - Street 1:8391 S SHADY TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-8652
Mailing Address - Country:US
Mailing Address - Phone:317-743-0009
Mailing Address - Fax:
Practice Address - Street 1:8391 S SHADY TRAIL DR
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-8652
Practice Address - Country:US
Practice Address - Phone:317-507-2395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1821290743Medicaid