Healthcare Provider Details

I. General information

NPI: 1770638413
Provider Name (Legal Business Name): ROCKY JAMES GIPSON HS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USCGC BERTHOLF (WMSL-750) COAST GUARD ISLAND
ALAMEDA CA
94501
US

IV. Provider business mailing address

4200 SPRING VALLEY DR S
MOBILE AL
36693-4358
US

V. Phone/Fax

Practice location:
  • Phone: 251-610-2142
  • Fax:
Mailing address:
  • Phone: 251-610-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: