=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669529970
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. KALUB GERRARD SHIPMAN SR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1719 BRISTOL RD
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406-3854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-327-7976
-----------------------------------------------------
Fax | 336-271-2155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1719 BRISTOL RD
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406-3854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-327-7976
-----------------------------------------------------
Fax | 336-271-2155
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | HC1786
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------