=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003935750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTON FAMILY HEALTH SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 10/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 WEST PENNSYLVANIA AVENUE
-----------------------------------------------------
City | BESSEMER CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28016-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-629-3465
-----------------------------------------------------
Fax | 704-629-1355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 E 2ND AVE
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28052-4358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-874-1904
-----------------------------------------------------
Fax | 704-864-7608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS SERVICE ADMIN
-----------------------------------------------------
Name | SHARMILA ALEXANDER ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-874-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------