Provider Demographics
NPI:1336910587
Name:GO TYME GRYND LLC
Entity Type:Organization
Organization Name:GO TYME GRYND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-709-0509
Mailing Address - Street 1:1836 DORR ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-3701
Mailing Address - Country:US
Mailing Address - Phone:419-702-0509
Mailing Address - Fax:
Practice Address - Street 1:3403 MONROE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-4140
Practice Address - Country:US
Practice Address - Phone:419-509-0509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health