Provider Demographics
NPI:1245477488
Name:GIBBS, CALVIN
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
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 5141
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-5141
Mailing Address - Country:US
Mailing Address - Phone:803-212-1055
Mailing Address - Fax:
Practice Address - Street 1:2611 FOREST DR
Practice Address - Street 2:SUITE 103 OFFICE 116
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2379
Practice Address - Country:US
Practice Address - Phone:803-212-1055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
6171270002Medicare NSC