Provider Demographics
NPI:1932899630
Name:GLL CENTER, LLC
Entity Type:Organization
Organization Name:GLL CENTER, LLC
Other - Org Name:GLL CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-874-9709
Mailing Address - Street 1:10700 BEACH BLVD UNIT 16428
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-3657
Mailing Address - Country:US
Mailing Address - Phone:904-874-9709
Mailing Address - Fax:
Practice Address - Street 1:4268 OLDFIELD CROSSING DR STE 303
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7899
Practice Address - Country:US
Practice Address - Phone:904-874-9709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-08
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty