Provider Demographics
NPI:1518068089
Name:GIPSON, LILI D (DC)
Entity Type:Individual
Prefix:
First Name:LILI
Middle Name:D
Last Name:GIPSON
Suffix:
Gender:F
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:PO BOX 2363
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-0007
Mailing Address - Country:US
Mailing Address - Phone:770-924-9400
Mailing Address - Fax:
Practice Address - Street 1:715A BASCOMB COMMERCIAL PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-2466
Practice Address - Country:US
Practice Address - Phone:770-924-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3030111N00000X, 111NN1001X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCBHTMedicare ID - Type UnspecifiedMEDICARE #
GAUO8409Medicare UPIN