Healthcare Provider Details

I. General information

NPI: 1235709411
Provider Name (Legal Business Name): STEPHEN GANT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 CHICAGO AVE STE J3
RIVERSIDE CA
92507-2358
US

IV. Provider business mailing address

6974 CARMELA WAY
FONTANA CA
92336-1491
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-2200
  • Fax:
Mailing address:
  • Phone: 443-315-6599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number300232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: