Provider Demographics
NPI:1336368539
Name:GIBSON CHIROPRACTIC PA
Entity Type:Organization
Organization Name:GIBSON CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:479-587-0227
Mailing Address - Street 1:93 W COLT SQUARE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2814
Mailing Address - Country:US
Mailing Address - Phone:479-587-0227
Mailing Address - Fax:479-587-0227
Practice Address - Street 1:93 W COLT SQUARE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2814
Practice Address - Country:US
Practice Address - Phone:479-587-0227
Practice Address - Fax:479-587-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1322111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U44562Medicare UPIN
AR5B410Medicare ID - Type Unspecified