Provider Demographics
NPI:1861490161
Name:GASTON MEMORIAL HOME HEALTH CARE/MED.INC.
Entity type:Organization
Organization Name:GASTON MEMORIAL HOME HEALTH CARE/MED.INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBER
Authorized Official - Middle Name:Z
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-834-2025
Mailing Address - Street 1:PO BOX 2568
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28053-2568
Mailing Address - Country:US
Mailing Address - Phone:704-834-2025
Mailing Address - Fax:704-834-2038
Practice Address - Street 1:200 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4358
Practice Address - Country:US
Practice Address - Phone:704-834-2025
Practice Address - Fax:704-834-2038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC0906251E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251E00000XAgenciesHome Health
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7100452Medicaid
NC3408315Medicaid
NC3417131Medicaid
NC6800451Medicaid
NC6600071Medicaid
NC7703688Medicaid
NCHC0906OtherDIVISION OF FACILITY SERV
NC3408315Medicaid
NC7703688Medicaid