Provider Demographics
NPI:1326235821
Name:GASTON FAMILY HEALTH SERVICES INC
Entity Type:Organization
Organization Name:GASTON FAMILY HEALTH SERVICES INC
Other - Org Name:KINTEGRA FAMILY MEDICINE - STATESVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS SERVICE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:SHARMILA
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-874-1907
Mailing Address - Street 1:1022 SHELTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-6826
Mailing Address - Country:US
Mailing Address - Phone:704-768-2080
Mailing Address - Fax:704-768-2085
Practice Address - Street 1:1022 SHELTON AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-6826
Practice Address - Country:US
Practice Address - Phone:704-838-1234
Practice Address - Fax:704-768-2081
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GASTON FAMILY HEALTH SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-28
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0497686Medicaid
3409807OtherNCPDP PROVIDER IDENTIFICATION NUMBER