Provider Demographics
NPI:1215654900
Name:GIBBS, COREY DWAYNE
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:DWAYNE
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 PLANTATION BLVD SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4119
Mailing Address - Country:US
Mailing Address - Phone:404-717-7631
Mailing Address - Fax:
Practice Address - Street 1:1040 PLANTATION BLVD SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-4119
Practice Address - Country:US
Practice Address - Phone:404-717-7631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care