Provider Demographics
NPI:1255947297
Name:GLUCKSTADT TC KIDS, LLC
Entity type:Organization
Organization Name:GLUCKSTADT TC KIDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-499-0651
Mailing Address - Street 1:1107 HIGHLAND COLONY PKWY STE 219
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-6079
Mailing Address - Country:US
Mailing Address - Phone:601-707-3279
Mailing Address - Fax:601-707-3598
Practice Address - Street 1:101 LEXINGTON DR STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6986
Practice Address - Country:US
Practice Address - Phone:601-707-3772
Practice Address - Fax:601-707-3772
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRUSTCARE HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-16
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty