Provider Demographics
NPI:1184397713
Name:GENTLE STICKS ON WHEELS
Entity type:Organization
Organization Name:GENTLE STICKS ON WHEELS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALYSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-431-1193
Mailing Address - Street 1:1829 FOREST GLEN DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-6565
Mailing Address - Country:US
Mailing Address - Phone:352-431-1193
Mailing Address - Fax:
Practice Address - Street 1:1829 FOREST GLEN DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-6565
Practice Address - Country:US
Practice Address - Phone:352-431-1193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-29
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty
No246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1942884846Medicaid