MEDICARE: MICKEY GIBSON

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	376J00000X	Homemaker

General Provider Information

NPI Number	:	1134824519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICKEY GIBSON

Provider Business Mailing Address
First Line	:	126 PLANTATION TRCE
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71112-8806
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	126 PLANTATION TRCE
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71112-8806
Country	:	US
Telephone Number	:	318-245-1120
Fax Number	:

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

Provider Enumeration Date	:	04/04/2023
Last Update Date	:	04/04/2023

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Directions to “ MICKEY GIBSON ” Practice Location

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