1316140551 NPI number — DR. KELLY MARIE GIBSON D.C.

Table of content: DR. KELLY MARIE GIBSON D.C. (NPI 1316140551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316140551 NPI number — DR. KELLY MARIE GIBSON D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
KELLY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIBSON COUCH
Provider Other First Name:
KELLY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316140551
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1929 W VISTA WAY STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VISTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92083-6018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-724-5700
Provider Business Mailing Address Fax Number:
760-724-9878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1929 W VISTA WAY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-724-5700
Provider Business Practice Location Address Fax Number:
760-724-9878
Provider Enumeration Date:
06/06/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111NI0900X , with the licence number:  DC25328 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: DC25328 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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