Healthcare Provider Details

I. General information

NPI: 1104668532
Provider Name (Legal Business Name): DOMINIC T GIBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 STUDEBAKER RD
NORWALK CA
90650-2531
US

IV. Provider business mailing address

906 OAKHORNE DR
HARBOR CITY CA
90710-1524
US

V. Phone/Fax

Practice location:
  • Phone: 855-464-2234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95192655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: