Provider Demographics
NPI:1922682517
Name:GIBSON, JAMES RANDALL (HIS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RANDALL
Last Name:GIBSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 W EVERLY BROS BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42330-1822
Mailing Address - Country:US
Mailing Address - Phone:270-754-2268
Mailing Address - Fax:270-757-2188
Practice Address - Street 1:1204 W EVERLY BROS BLVD
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:KY
Practice Address - Zip Code:42330-1822
Practice Address - Country:US
Practice Address - Phone:270-754-2268
Practice Address - Fax:270-757-2188
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY270009237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty