Provider Demographics
NPI:1447889274
Name:GO GENTLY MEDICAL GROUP. INC
Entity type:Organization
Organization Name:GO GENTLY MEDICAL GROUP. INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF QUALITY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-760-5743
Mailing Address - Street 1:206 N 2100 W STE 202
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4741
Mailing Address - Country:US
Mailing Address - Phone:801-325-0175
Mailing Address - Fax:801-478-3533
Practice Address - Street 1:2140 PROFESSIONAL DR STE 210
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3776
Practice Address - Country:US
Practice Address - Phone:916-970-1700
Practice Address - Fax:916-751-7290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-03
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty