1710209473 NPI number — GASTON FAMILY HEALTH SERVICES INC

Table of content: (NPI 1710209473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710209473 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:
6
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:
1710209473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 E SECOND 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:
704-874-1904
Provider Business Mailing Address Fax Number:
704-867-2134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 GAMBLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLNTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28092-4421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-735-7145
Provider Business Practice Location Address Fax Number:
704-732-7522
Provider Enumeration Date:
02/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
SHARMILA
Authorized Official Middle Name:
ALEXANDER
Authorized Official Title or Position:
BUSINESS SERVICE ADMINISTRATOR
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)

  • Identifier: 344031A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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