Healthcare Provider Details

I. General information

NPI: 1285885673
Provider Name (Legal Business Name): TYRONE AARON GIBSON A.B.O.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 10/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5014 VIRGINIA AVE APT 2W
SAINT LOUIS MO
63111-1739
US

IV. Provider business mailing address

5014 VIRGINIA AVE APT 2W
SAINT LOUIS MO
63111-1739
US

V. Phone/Fax

Practice location:
  • Phone: 202-487-1337
  • Fax:
Mailing address:
  • Phone: 202-487-1337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: