=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043818693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 100 PERCENT CHIROPRACTIC GIBSON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2020
-----------------------------------------------------
Last Update Date | 10/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 CHARLEY HARPER DR STE 140
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120-0027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-614-1795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 CHARLEY HARPER DR STE 140
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120-0027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-614-1795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. JUSTIN BRUCE GIBSON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 912-614-1795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------