Healthcare Provider Details

I. General information

NPI: 1700815495
Provider Name (Legal Business Name): HENDRICK D GANDING PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11336 BARTLETT AVE 11
ADELANTO CA
92301-1948
US

IV. Provider business mailing address

11336 BARTLETT AVE 11
ADELANTO CA
92301-1948
US

V. Phone/Fax

Practice location:
  • Phone: 760-246-8846
  • Fax: 760-246-3118
Mailing address:
  • Phone: 760-246-8846
  • Fax: 760-246-3118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22216
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: