Provider Demographics
NPI:1477079283
Name:GASTON FAMILY HEALTH SERVICES INC
Entity Type:Organization
Organization Name:GASTON FAMILY HEALTH SERVICES INC
Other - Org Name:KINTEGRA ADULT & PEDIATRIC MEDICINE - XRAY DR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS SERVICES ADMINISTRATOR
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 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:704-864-7608
Practice Address - Street 1:2721 X RAY DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7491
Practice Address - Country:US
Practice Address - Phone:704-874-2255
Practice Address - Fax:704-852-4092
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GASTON FAMILY HEALTH SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X, 333600000X
NC133523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1477079283Medicaid
2171517OtherPK