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General NPI Number Information
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NPI Number | 1578077228
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Entity Type | Individual
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Provider Name | FRED LLOYD GIBSON IV DC
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Gender | Male
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Dates
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Enumeration Date | 11/16/2017
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Last Update Date | 09/26/2023
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Provider Practice Location Address
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Address Line | 12627 SAN JOSE BLVD STE 305
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City | JACKSONVILLE
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State | FL
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Zip | 32223-8639
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Country | US
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Telephone | 904-683-4376
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Fax |
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Provider Business Mailing Address
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Address Line | 379 LAKE KATHRYN CIR
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City | CASSELBERRY
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State | FL
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Zip | 32707-3001
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Country | US
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Telephone | 407-949-7037
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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 | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 12141
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License Number State | FL
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