Healthcare Provider Details

I. General information

NPI: 1619431210
Provider Name (Legal Business Name): DEBORAH D GIBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 S BROADWAY
SHELBY MS
38774
US

IV. Provider business mailing address

1806 S CHRISMAN AVE
CLEVELAND MS
38732-4504
US

V. Phone/Fax

Practice location:
  • Phone: 662-775-5070
  • Fax: 662-775-5070
Mailing address:
  • Phone: 662-775-5070
  • Fax: 662-775-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: