=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376628578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIBSON CARE CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 07/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 608 SIGNAL HILL DRIVE EXT
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28625-4353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-924-9909
-----------------------------------------------------
Fax | 704-924-9165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7138
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28687-7138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-924-9909
-----------------------------------------------------
Fax | 704-924-9165
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FRANCHISE OWNER
-----------------------------------------------------
Name | MR. JAMES CREIGHTON GIBSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-924-9909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HC3016
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | HC3016
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------