Provider Demographics
NPI:1619308954
Name:GIBSON, GLENN M (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 CLOVER ST
Mailing Address - Street 2:
Mailing Address - City:WEST HURLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12491-6019
Mailing Address - Country:US
Mailing Address - Phone:845-663-8299
Mailing Address - Fax:
Practice Address - Street 1:400 KINGS MALL CT
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1578
Practice Address - Country:US
Practice Address - Phone:846-663-8299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012425111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor