Provider Demographics
NPI:1598438087
Name:GIBBS, CHARLES LARRY JR (DACM, LAC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LARRY
Last Name:GIBBS
Suffix:JR
Gender:M
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 AMBER CREEK RD UNIT 54
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1938
Mailing Address - Country:US
Mailing Address - Phone:615-618-0443
Mailing Address - Fax:
Practice Address - Street 1:13214 FOUNTAIN HEAD PLZ
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2678
Practice Address - Country:US
Practice Address - Phone:301-766-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02716171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist