Provider Demographics
NPI:1669434213
Name:GIBSON, KEVIN CRAIG (DC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:CRAIG
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 1:165 WILLOW BEND DR
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8750
Mailing Address - Country:US
Mailing Address - Phone:330-533-7382
Mailing Address - Fax:
Practice Address - Street 1:315 STRUTHERS LIBERTY RD
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:OH
Practice Address - Zip Code:44405-1949
Practice Address - Country:US
Practice Address - Phone:330-750-1333
Practice Address - Fax:330-750-0203
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDC1980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0936232Medicaid
OH0936232Medicaid
OHU43973Medicare UPIN