Healthcare Provider Details

I. General information

NPI: 1306768759
Provider Name (Legal Business Name): QUINCY O GAMBLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1993 OAK TREE LN
CAHOKIA IL
62206-1406
US

IV. Provider business mailing address

1993 OAK TREE LN
CAHOKIA IL
62206-1406
US

V. Phone/Fax

Practice location:
  • Phone: 618-855-6986
  • Fax:
Mailing address:
  • Phone: 618-855-6986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License NumberG51471474354
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: