=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376693978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIBSON PERSONAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2007
-----------------------------------------------------
Last Update Date | 06/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 COUNTY ROAD 3823
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78253-6934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-738-9000
-----------------------------------------------------
Fax | 210-738-9018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 COUNTY ROAD 3823
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78253-6934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-738-9000
-----------------------------------------------------
Fax | 210-738-9018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER ADMINISTRATOR
-----------------------------------------------------
Name | MRS. CAROL A GIBSON
-----------------------------------------------------
Credential | LVN
-----------------------------------------------------
Telephone | 210-738-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 010694
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------