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General NPI Number Information
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NPI Number | 1215654900
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Entity Type | Individual
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Provider Name | COREY DWAYNE GIBBS
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Gender | Male
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Dates
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Enumeration Date | 10/24/2022
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Last Update Date | 10/24/2022
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Provider Practice Location Address
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Address Line | 1040 PLANTATION BLVD SE
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City | CONYERS
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State | GA
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Zip | 30094-4119
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Country | US
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Telephone | 404-717-7631
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Fax |
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Provider Business Mailing Address
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Address Line | 1040 PLANTATION BLVD SE
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City | CONYERS
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State | GA
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Zip | 30094-4119
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Country | US
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Telephone | 404-717-7631
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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License Number State |
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