MEDICARE: VICTORIA SIMMONS GIBSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1619142759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA SIMMONS GIBSON

Provider Business Mailing Address
First Line	:	2673 NANCY DR
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31206-4940
Country	:	US
Telephone Number	:	478-781-4134
Fax Number	:	478-254-2453

Provider Business Practice Location Address
First Line	:	2673 NANCY DR
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31206-4940
Country	:	US
Telephone Number	:	478-781-4134
Fax Number	:	478-254-2453

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	04/30/2008

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