Provider Demographics
NPI:1659739530
Name:GORGEOSO LLC
Entity Type:Organization
Organization Name:GORGEOSO LLC
Other - Org Name:AVERAGE JOE'S FITNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:DRUZBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-381-9756
Mailing Address - Street 1:90 W CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:ROTTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12306-6847
Mailing Address - Country:US
Mailing Address - Phone:518-377-5637
Mailing Address - Fax:
Practice Address - Street 1:90 W CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:ROTTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12306-6847
Practice Address - Country:US
Practice Address - Phone:518-377-5637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization