Provider Demographics
NPI:1710715370
Name:GAUTIER WELLNESS LLC
Entity type:Organization
Organization Name:GAUTIER WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GATZ
Authorized Official - Suffix:
Authorized Official - Credentials:ARDMS
Authorized Official - Phone:816-448-9515
Mailing Address - Street 1:14805 BURRELL RD
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-8483
Mailing Address - Country:US
Mailing Address - Phone:816-448-9515
Mailing Address - Fax:
Practice Address - Street 1:4535B GAUTIER VANCLEAVE RD
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-4810
Practice Address - Country:US
Practice Address - Phone:228-641-9401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory