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General NPI Number Information
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NPI Number | 1114121324
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Entity Type | Organization
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Legal Business Name | WENDY SOWELL GIBSON OD
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Dates
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Enumeration Date | 06/12/2007
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Last Update Date | 11/14/2013
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Provider Practice Location Address
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Address Line | 1512 MAIN ST
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City | BENTON
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State | KY
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Zip | 42025-1607
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Country | US
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Telephone | 270-527-0951
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Fax | 270-527-1316
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Provider Business Mailing Address
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Address Line | 1512 MAIN ST
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City | BENTON
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State | KY
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Zip | 42025-1607
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Country | US
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Telephone | 270-527-0951
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Fax | 270-527-1316
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Authorized Official
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Title or Position | OWNER
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Name | DR. WENDY GIBSON
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Credential | OD
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Telephone | 270-527-0951
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 911DT
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License Number State | KY
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