Basic Information
Provider Information | |||||||||
NPI: | 1578128757 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GASTON FAMILY HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KINTEGRA AT A WOMAN'S VIEW | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 E 2ND AVE | ||||||||
Address2: |   | ||||||||
City: | GASTONIA | ||||||||
State: | NC | ||||||||
PostalCode: | 280524358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048741904 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 915 TATE BLVD SE | ||||||||
Address2: |   | ||||||||
City: | HICKORY | ||||||||
State: | NC | ||||||||
PostalCode: | 286024042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8283450800 | ||||||||
FaxNumber: | 8283450350 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2019 | ||||||||
LastUpdateDate: | 02/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON | ||||||||
AuthorizedOfficialFirstName: | SHARMILA | ||||||||
AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS SERVICE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 7048741907 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GASTON FAMILY HEALTH SERVICES, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.