Provider Demographics
NPI:1174141758
Name:REGINA GIBBONS MBA LIC AC
Entity type:Organization
Organization Name:REGINA GIBBONS MBA LIC AC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:LIC AC
Authorized Official - Phone:781-639-0037
Mailing Address - Street 1:358 LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-4821
Mailing Address - Country:US
Mailing Address - Phone:781-369-0037
Mailing Address - Fax:
Practice Address - Street 1:18 TRAPELO RD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-4400
Practice Address - Country:US
Practice Address - Phone:781-639-0037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty