Provider Demographics
NPI:1417088824
Name:GIBBS, EDWIN CHARLES (DC ND LAC)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:CHARLES
Last Name:GIBBS
Suffix:
Gender:M
Credentials:DC ND LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 N HOLLADAY DR
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138
Mailing Address - Country:US
Mailing Address - Phone:503-738-7343
Mailing Address - Fax:503-738-9946
Practice Address - Street 1:45 N HOLLADAY DR
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138
Practice Address - Country:US
Practice Address - Phone:503-738-7343
Practice Address - Fax:503-738-9946
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272219111N00000X
ORAC00733171100000X
OR1078175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR862925004OtherREGENCE BLUE CROSS
OR213146Medicaid
OR076724Medicaid
OR862925003OtherREGENCE BLUE CROSS
OR862925001OtherREGENCE BLUE CROSS
OR862925004OtherREGENCE BLUE CROSS