Provider Demographics
NPI:1417061268
Name:GIBSON, BRIAN C (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-5572
Mailing Address - Country:US
Mailing Address - Phone:941-488-5553
Mailing Address - Fax:941-488-7444
Practice Address - Street 1:153 CENTER RD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-5572
Practice Address - Country:US
Practice Address - Phone:941-488-5553
Practice Address - Fax:941-218-6596
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4236111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4228OtherMEDICARE PTAN
FLU4228Medicare PIN
FLT73194Medicare UPIN