MEDICARE: PATRICIA JEANNE GAMBOA DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3512	NC

General Provider Information

NPI Number	:	1013262526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA JEANNE GAMBOA DC

Provider Business Mailing Address
First Line	:	4805 PARK RD
Second Line	:	STE 225
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3803
Country	:	US
Telephone Number	:	704-527-7246
Fax Number	:	704-527-3080

Provider Business Practice Location Address
First Line	:	4805 PARK RD
Second Line	:	STE 225
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3803
Country	:	US
Telephone Number	:	704-527-7246
Fax Number	:	704-527-3080

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2012
Last Update Date	:	07/20/2012

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