Provider Demographics
NPI:1528290145
Name:PELOQUIN, GARY (LMT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:PELOQUIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 NE DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-6445
Mailing Address - Country:US
Mailing Address - Phone:772-225-5555
Mailing Address - Fax:772-225-0675
Practice Address - Street 1:1830 NE DIXIE HWY
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-6445
Practice Address - Country:US
Practice Address - Phone:772-225-5555
Practice Address - Fax:772-225-0675
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-15
Last Update Date:2009-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA23030173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA23030OtherSTATE MASSAGE THERAPY LICENSE