Provider Demographics
NPI:1336686153
Name:KELLY GIBSONCHIROPRACTIC, INC
Entity Type:Organization
Organization Name:KELLY GIBSONCHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-724-5700
Mailing Address - Street 1:1929 W VISTA WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6004
Mailing Address - Country:US
Mailing Address - Phone:760-724-5700
Mailing Address - Fax:760-724-9878
Practice Address - Street 1:1929 W VISTA WAY
Practice Address - Street 2:SUITE C
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6004
Practice Address - Country:US
Practice Address - Phone:760-724-5700
Practice Address - Fax:760-724-9878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25328111NI0900X, 111NN1001X, 111NR0400X
CADC10902111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Multi-Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty