MEDICARE: MR. HENRY ALLEN GOCKENBACH P.T., A.T.C

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	PT19109	FL
2	2255A2300X	Athletic Trainer	AL1142	FL

General Provider Information

NPI Number	:	1881631653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HENRY ALLEN GOCKENBACH P.T., A.T.C

Provider Business Mailing Address
First Line	:	3761 SW WYCOFF ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-5318
Country	:	US
Telephone Number	:	772-532-1834
Fax Number	:	772-464-3365

Provider Business Practice Location Address
First Line	:	3761 SW WYCOFF ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-5318
Country	:	US
Telephone Number	:	772-532-1834
Fax Number	:	772-464-3365

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	01/27/2008

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