Healthcare Provider Details

I. General information

NPI: 1336686153
Provider Name (Legal Business Name): KELLY GIBSONCHIROPRACTIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1929 W VISTA WAY SUITE C
VISTA CA
92083-6004
US

IV. Provider business mailing address

1929 W VISTA WAY SUITE C
VISTA CA
92083-6004
US

V. Phone/Fax

Practice location:
  • Phone: 760-724-5700
  • Fax: 760-724-9878
Mailing address:
  • Phone: 760-724-5700
  • Fax: 760-724-9878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License NumberDC25328
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberDC25328
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC25328
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC10902
License Number StateCA

VIII. Authorized Official

Name: DR. KELLY MARIE GIBSON
Title or Position: PRESIDENT
Credential: D.C.
Phone: 760-724-5700