Provider Demographics
NPI:1316140551
Name:GIBSON, KELLY MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:GIBSON COUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1929 W VISTA WAY STE C
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6018
Mailing Address - Country:US
Mailing Address - Phone:760-724-5700
Mailing Address - Fax:760-724-9878
Practice Address - Street 1:1929 W VISTA WAY
Practice Address - Street 2:SUITE C
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083
Practice Address - Country:US
Practice Address - Phone:760-724-5700
Practice Address - Fax:760-724-9878
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25328111NI0900X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU71203Medicare ID - Type Unspecified