Provider Demographics
NPI:1003423013
Name:GIBSON, CHARLES KEITH
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:KEITH
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 ANN ELISE CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-6211
Mailing Address - Country:US
Mailing Address - Phone:513-907-1843
Mailing Address - Fax:
Practice Address - Street 1:4110 ANN ELISE CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45011-6211
Practice Address - Country:US
Practice Address - Phone:513-907-1843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care