Provider Demographics
NPI:1710384979
Name:GBT LBA
Entity Type:Organization
Organization Name:GBT LBA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:COKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-518-9654
Mailing Address - Street 1:2895 EGRET CT
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-2369
Mailing Address - Country:US
Mailing Address - Phone:904-518-9654
Mailing Address - Fax:904-724-5770
Practice Address - Street 1:3101 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2790
Practice Address - Country:US
Practice Address - Phone:904-518-9654
Practice Address - Fax:904-724-5770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208VP0014X261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
1427002799OtherNPI