Provider Demographics
NPI:1235688722
Name:GIBSON WINGATE, RICHARDEAN (MLT)
Entity Type:Individual
Prefix:
First Name:RICHARDEAN
Middle Name:
Last Name:GIBSON WINGATE
Suffix:
Gender:F
Credentials:MLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29503-0376
Mailing Address - Country:US
Mailing Address - Phone:843-245-4708
Mailing Address - Fax:843-407-6607
Practice Address - Street 1:605 S DARGAN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2544
Practice Address - Country:US
Practice Address - Phone:843-245-4708
Practice Address - Fax:843-407-6607
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMAS7994225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist