Provider Demographics
NPI:1013680388
Name:GIBRALTAR BIZ, LLC
Entity Type:Organization
Organization Name:GIBRALTAR BIZ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRITHA
Authorized Official - Middle Name:SKINNER
Authorized Official - Last Name:DINWIDDIE
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:678-485-3308
Mailing Address - Street 1:5505 E MOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3027
Mailing Address - Country:US
Mailing Address - Phone:678-485-3308
Mailing Address - Fax:
Practice Address - Street 1:5505 E MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3027
Practice Address - Country:US
Practice Address - Phone:678-485-3308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-31
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD1103OtherSTATE BOARD OF LICENSURE
TXDT85347OtherSTATE BOARD OF LICENSURE
FLND9557OtherSTATE BOARD OF LICENSURE
677280OtherCOMMISSION ON DIETETIC REGISTRATION, ACADEMY OF NUTRITION AND DIETETICS
NCL003247OtherSTATE BOARD OF LICENSURE
GA1093126997Medicaid
AL893OtherSTATE BOARD OF LICENSURE
KS2273OtherSTATE BOARD OF LICENSURE
GA878OtherSTATE BOARD OF LICENSURE
TNLDN2393OtherSTATE BOARD OF LICENSURE