Healthcare Provider Details

I. General information

NPI: 1245477488
Provider Name (Legal Business Name): CALVIN GIBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 FOREST DR SUITE 103 OFFICE 116
COLUMBIA SC
29204-2379
US

IV. Provider business mailing address

PO BOX 5141
WEST COLUMBIA SC
29171-5141
US

V. Phone/Fax

Practice location:
  • Phone: 803-212-1055
  • Fax:
Mailing address:
  • Phone: 803-212-1055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: