Healthcare Provider Details

I. General information

NPI: 1578719886
Provider Name (Legal Business Name): GASTON FAMILY HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 NE ASHLEY SCHOOL CIRCLE
WINSTON-SALEM NC
27105-5444
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 336-703-4205
  • Fax: 336-245-4592
Mailing address:
  • Phone: 704-874-1904
  • Fax: 704-874-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHARMILA ANDERSON
Title or Position: BUSINESS SERVICES ADMINISTRATOR
Credential:
Phone: 704-874-1907