MEDICARE: MARIANO FREDERICO GAVIOLA

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	014901-1	NY

General Provider Information

NPI Number	:	1558580647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIANO FREDERICO GAVIOLA

Provider Business Mailing Address
First Line	:	2244 PALISADES CENTER DR
Second Line	:
City	:	WEST NYACK
State	:	NY
Zip	:	10994-6402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	28B INDIAN ROCK
Second Line	:
City	:	MONTEBELLO
State	:	NY
Zip	:	10901-4907
Country	:	US
Telephone Number	:	845-368-2180
Fax Number	:

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

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	12/22/2023

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