Basic Information
| Provider Information | |||||||||
| NPI: | 1558643379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTON FAMILY HEALTH SERVICES, INC. | ||||||||
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| OtherOrganizationName: | GFHS SCHOOL BASED SOCIAL WORK PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 E 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280524358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048741904 | ||||||||
| FaxNumber: | 7048740707 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 N. CHERRY ST. | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271012933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367484025 | ||||||||
| FaxNumber: | 3367484108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2011 | ||||||||
| LastUpdateDate: | 01/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | SHARMILA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS SERVICES ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7048741907 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | N | Ambulatory Health Care Facilities | Clinic/Center | Student Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 6008681 | 05 | NC | MEDICAID |