Basic Information
| Provider Information | |||||||||
| NPI: | 1215014840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBBONS | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPT 111 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12440 E. IMPERIAL HWY. | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906503177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008547771 | ||||||||
| FaxNumber: | 5628683749 | ||||||||
| Practice Location | |||||||||
| Address1: | 12440 IMPERIAL HWY | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906503177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008547771 | ||||||||
| FaxNumber: | 5628683749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT 19568 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.