Healthcare Provider Details

I. General information

NPI: 1205466398
Provider Name (Legal Business Name): GASTON FAMILY HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 BROOKDALE DR
STATESVILLE NC
28677-4108
US

IV. Provider business mailing address

518 BROOKDALE DR
STATESVILLE NC
28677-4108
US

V. Phone/Fax

Practice location:
  • Phone: 704-838-1108
  • Fax: 704-671-1404
Mailing address:
  • Phone: 704-838-1108
  • Fax: 704-671-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: SHARMILA ALEXANDER ANDERSON
Title or Position: BUSINES SERVICE ADMINISTRATOR
Credential:
Phone: 704-874-1907