Provider Demographics
NPI:1992348551
Name:GIBSON, CHARLES C
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:GIBSON
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 1:790 ROBERTS DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-5723
Mailing Address - Country:US
Mailing Address - Phone:870-723-5324
Mailing Address - Fax:870-460-6133
Practice Address - Street 1:1404 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671
Practice Address - Country:US
Practice Address - Phone:870-226-6955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator