=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962484543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAVENSCROFT 58 INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2005
-----------------------------------------------------
Last Update Date | 01/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 WAYNESVILLE PLAZA STE 1
-----------------------------------------------------
City | WAYNESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-456-5700
-----------------------------------------------------
Fax | 828-456-5728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136 WAYNESVILLE PLAZA STE 1
-----------------------------------------------------
City | WAYNESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-456-5700
-----------------------------------------------------
Fax | 828-456-5728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CRAIG EDWARD GIBSON SR.
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 828-456-5700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1700
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------