Provider Demographics
NPI:1578719886
Name:GASTON FAMILY HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:GASTON FAMILY HEALTH SERVICES, INC.
Other - Org Name:KINTEGRA/SHA AT ASHLEY WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS SERVICES ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARMILA
Authorized Official - Middle Name:
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:704-874-0707
Practice Address - Street 1:1647 NE ASHLEY SCHOOL CIRCLE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-5444
Practice Address - Country:US
Practice Address - Phone:336-703-4205
Practice Address - Fax:336-245-4592
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GASTON FAMILY HEALTH SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-18
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X, 261QM0855X
NC261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005802Medicaid