Provider Demographics
NPI:1174905418
Name:GIBBONS CHIROPRACTIC AND ACUPUNCTURE LLC
Entity type:Organization
Organization Name:GIBBONS CHIROPRACTIC AND ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:937-703-9328
Mailing Address - Street 1:50 TROY TOWN DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2341
Mailing Address - Country:US
Mailing Address - Phone:937-703-9328
Mailing Address - Fax:937-703-9329
Practice Address - Street 1:50 TROY TOWN DR
Practice Address - Street 2:SUITE B
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2341
Practice Address - Country:US
Practice Address - Phone:937-703-9328
Practice Address - Fax:937-703-9329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4107111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4314051Medicare UPIN