Healthcare Provider Details

I. General information

NPI: 1649284019
Provider Name (Legal Business Name): GARY MARK AGCAOILI C.T.R.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 CLEMENT ST
SAN FRANCISCO CA
94121-1545
US

IV. Provider business mailing address

3520 PARK RIDGE DR
RICHMOND CA
94806-5824
US

V. Phone/Fax

Practice location:
  • Phone: 415-221-4810
  • Fax:
Mailing address:
  • Phone: 510-685-5206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number32223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: