1104500701 NPI number — GASTON FAMILY HEALTH SERVICES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104500701 NPI number — GASTON FAMILY HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTON FAMILY HEALTH SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104500701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 E 2ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GASTONIA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28052-4358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CEDARBROOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28642-2405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-551-1148
Provider Business Practice Location Address Fax Number:
336-551-1149
Provider Enumeration Date:
06/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
SHARMILA
Authorized Official Middle Name:
ALEXANDER
Authorized Official Title or Position:
REVENUE CYCLE MANAGER
Authorized Official Telephone Number:
704-874-1907

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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