Provider Demographics
NPI:1316030174
Name:PIACENTINE, GARY JAMES (PT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:JAMES
Last Name:PIACENTINE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W LAKE MARY BLVD
Mailing Address - Street 2:102
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-5946
Mailing Address - Country:US
Mailing Address - Phone:407-321-6644
Mailing Address - Fax:407-321-7309
Practice Address - Street 1:820 W LAKE MARY BLVD
Practice Address - Street 2:102
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-5946
Practice Address - Country:US
Practice Address - Phone:407-321-6644
Practice Address - Fax:407-321-7309
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT1410225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY922POtherBC/BS NUMBER
FLPT1410OtherPT LICENSE #
FLDA8737Medicare ID - Type UnspecifiedMEDICARE RAIL ROAD #
FLY3855ZMedicare ID - Type UnspecifiedTHERAPIST PERSONAL #
FLY922POtherBC/BS NUMBER