Healthcare Provider Details

I. General information

NPI: 1417473323
Provider Name (Legal Business Name): LGIBSON ANESTHESIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9674 ARCHIBALD AVE STE 125
RANCHO CUCAMONGA CA
91730-7944
US

IV. Provider business mailing address

5 HOLLAND STE 101
IRVINE CA
92618-2568
US

V. Phone/Fax

Practice location:
  • Phone: 909-296-8930
  • Fax: 909-296-8935
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateNULL

VIII. Authorized Official

Name: LORETTA GIBSON
Title or Position: PRESIDENT
Credential:
Phone: 949-588-2190