MEDICARE: MR. RAUL AGGABAO GAMMARU JR. PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	62166	OR

General Provider Information

NPI Number	:	1275842551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RAUL AGGABAO GAMMARU JR. PT

Provider Business Mailing Address
First Line	:	2216 TEAKWOOD AVE NW
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97304-1344
Country	:	US
Telephone Number	:	503-684-0311
Fax Number	:	503-689-8088

Provider Business Practice Location Address
First Line	:	2216 TEAKWOOD AVE NW
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97304-1344
Country	:	US
Telephone Number	:	503-684-0311
Fax Number	:	503-689-8088

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2010
Last Update Date	:	07/28/2020

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