Provider Demographics
NPI:1699715185
Name:REVENTAR, GABRIEL ELLO (PT)
Entity type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:ELLO
Last Name:REVENTAR
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 1:36 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-1205
Mailing Address - Country:US
Mailing Address - Phone:201-658-8983
Mailing Address - Fax:
Practice Address - Street 1:604 ROUTE 303
Practice Address - Street 2:
Practice Address - City:BLAUVELT
Practice Address - State:NY
Practice Address - Zip Code:10913-1161
Practice Address - Country:US
Practice Address - Phone:201-658-8983
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist