Provider Demographics
NPI:1104407147
Name:GANTIOQUI, GENEFREY
Entity type:Individual
Prefix:
First Name:GENEFREY
Middle Name:
Last Name:GANTIOQUI
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 1:8219 VALLEY VIEW ST
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2700
Mailing Address - Country:US
Mailing Address - Phone:562-612-6943
Mailing Address - Fax:
Practice Address - Street 1:8219 VALLEY VIEW ST
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-2700
Practice Address - Country:US
Practice Address - Phone:562-612-6943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10152225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant