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General NPI Number Information
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NPI Number | 1518721281
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Entity Type | Individual
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Provider Name | SHANON T GIBBS
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Gender | Male
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Dates
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Enumeration Date | 02/12/2024
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 2364 CARVER AVE
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City | KINGMAN
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State | AZ
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Zip | 86409
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Country | US
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Telephone | 928-757-3989
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Fax | 928-692-0398
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Provider Business Mailing Address
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Address Line | 1 E LEXINGTON AVE UNIT 1507
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City | PHOENIX
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State | AZ
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Zip | 85012-4202
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Country | US
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Telephone | 480-438-1399
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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 | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL12844C
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License Number State | AZ
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